Provider Demographics
NPI:1962844027
Name:BLAYLOCK, THERESA (MPA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 FLETCHER LN
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-1008
Mailing Address - Country:US
Mailing Address - Phone:510-247-8300
Mailing Address - Fax:510-886-1038
Practice Address - Street 1:795 FLETCHER LN
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-1008
Practice Address - Country:US
Practice Address - Phone:510-247-8300
Practice Address - Fax:510-886-1038
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)