Provider Demographics
NPI:1942358031
Name:BLASI, WICKLIFFE LOOMIS (LCSW)
Entity Type:Individual
Prefix:
First Name:WICKLIFFE
Middle Name:LOOMIS
Last Name:BLASI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 EL CAMINO REAL STE E
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2110
Mailing Address - Country:US
Mailing Address - Phone:760-434-1232
Mailing Address - Fax:760-632-8033
Practice Address - Street 1:3150 EL CAMINO REAL STE E
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2110
Practice Address - Country:US
Practice Address - Phone:760-434-1232
Practice Address - Fax:760-632-8033
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW85771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical