Provider Demographics
NPI:1801204722
Name:BLOUNT, TAMMY MARIE
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:MARIE
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 INDUSTRY WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-4283
Mailing Address - Country:US
Mailing Address - Phone:310-631-8004
Mailing Address - Fax:310-631-5875
Practice Address - Street 1:2610 INDUSTRY WAY
Practice Address - Street 2:SUITE A
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4283
Practice Address - Country:US
Practice Address - Phone:310-631-8004
Practice Address - Fax:310-631-5875
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2019-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF80740101YM0800X, 106H00000X
CALMFT111907106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health