Basic Information
| Provider Information | |||||||||
| NPI: | 1629255609 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANTON | ||||||||
| FirstName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4411 N CEDAR AVE STE 108 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937262538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592481548 | ||||||||
| FaxNumber: | 5592481530 | ||||||||
| Practice Location | |||||||||
| Address1: | 4705 N SONORA AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937223966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592767558 | ||||||||
| FaxNumber: | 5592767568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.