Provider Demographics
NPI:1023168937
Name:BLASINGAME, GERRY DALE (MA, LMFT)
Entity type:Individual
Prefix:MR
First Name:GERRY
Middle Name:DALE
Last Name:BLASINGAME
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3161 BECHELLI LANE
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002
Mailing Address - Country:US
Mailing Address - Phone:530-222-9225
Mailing Address - Fax:530-222-9227
Practice Address - Street 1:3161 BECHELLI LANE
Practice Address - Street 2:SUITE 201B
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002
Practice Address - Country:US
Practice Address - Phone:530-222-9225
Practice Address - Fax:530-222-9227
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 24816106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist