Provider Demographics
NPI:1932659844
Name:CK BLACKMORE MARRIAGE & FAMILY THERAPY, PROF CORP
Entity Type:Organization
Organization Name:CK BLACKMORE MARRIAGE & FAMILY THERAPY, PROF CORP
Other - Org Name:CK BLACKMORE PSYCHOTHERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:OLIVIERI
Authorized Official - Last Name:BLACKMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MFT, PHD
Authorized Official - Phone:518-269-5458
Mailing Address - Street 1:889 PERALTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-6241
Mailing Address - Country:US
Mailing Address - Phone:518-269-5458
Mailing Address - Fax:
Practice Address - Street 1:3150 18TH ST
Practice Address - Street 2:257
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2074
Practice Address - Country:US
Practice Address - Phone:518-269-5458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85721106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty