MEDICARE: ALICIA BLACKWOOD LMFT

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	82978	CA

General Provider Information

NPI Number	:	1659896942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA BLACKWOOD LMFT

Provider Business Mailing Address
First Line	:	467 62ND ST
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-1903
Country	:	US
Telephone Number	:	714-496-7789
Fax Number	:

Provider Business Practice Location Address
First Line	:	17155 NEWHOPE ST STE L
Second Line	:
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708-4233
Country	:	US
Telephone Number	:	714-496-7789
Fax Number	:

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

Provider Enumeration Date	:	08/07/2017
Last Update Date	:	08/07/2017

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Directions to “ ALICIA BLACKWOOD LMFT” Practice Location

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