Provider Demographics
NPI:1265712855
Name:BLOXSOM-CARTER, REXFORD ELLEDGE (MA)
Entity type:Individual
Prefix:
First Name:REXFORD
Middle Name:ELLEDGE
Last Name:BLOXSOM-CARTER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 ELM ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-8401
Mailing Address - Country:US
Mailing Address - Phone:805-338-8099
Mailing Address - Fax:
Practice Address - Street 1:995 POTRERO AVE
Practice Address - Street 2:BUILDING 80, BASEMENT
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2859
Practice Address - Country:US
Practice Address - Phone:415-206-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8121Medicaid