MEDICARE: MS. SUSAN LYNNE BLAINE MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC33852	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MFC33852	OTHER	CA	BBS LICENSE NUMBER

General Provider Information

NPI Number	:	1174542666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN LYNNE BLAINE MFT

Provider Business Mailing Address
First Line	:	1260 LAKE BLVD
Second Line	:	SUITE 243
City	:	DAVIS
State	:	CA
Zip	:	95616-2614
Country	:	US
Telephone Number	:	530-297-1601
Fax Number	:	530-297-6864

Provider Business Practice Location Address
First Line	:	1260 LAKE BLVD
Second Line	:	SUITE 243
City	:	DAVIS
State	:	CA
Zip	:	95616-2614
Country	:	US
Telephone Number	:	530-297-1601
Fax Number	:	530-297-6864

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/08/2007

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