Basic Information
| Provider Information | |||||||||
| NPI: | 1558608489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLONIGEN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 514 MISSOURI ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941072837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122274123 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 795 WILLOW RD | ||||||||
| Address2: | MPD-152 | ||||||||
| City: | MENLO PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940252539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504935000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2013 | ||||||||
| LastUpdateDate: | 01/11/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY 24592 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.