Healthcare Provider Details

I. General information

NPI: 1760770192
Provider Name (Legal Business Name): MARK DANIEL BLACKHURST PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3034 E HERNDON AVE
FRESNO CA
93720-0300
US

IV. Provider business mailing address

21633 AVENUE 24
CHOWCHILLA CA
93610-9650
US

V. Phone/Fax

Practice location:
  • Phone: 559-321-0883
  • Fax:
Mailing address:
  • Phone: 559-665-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY28115
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: