Provider Demographics
NPI:1205241163
Name:BLOCKDARE INC
Entity type:Organization
Organization Name:BLOCKDARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ABRAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,MFT
Authorized Official - Phone:626-429-3651
Mailing Address - Street 1:2260 BRENTFORD RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2801
Mailing Address - Country:US
Mailing Address - Phone:626-429-3651
Mailing Address - Fax:
Practice Address - Street 1:2260 BRENTFORD RD
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-2801
Practice Address - Country:US
Practice Address - Phone:626-429-3651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-29
Last Update Date:2014-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0M15046261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAM015046OtherNONE