Healthcare Provider Details

I. General information

NPI: 1417261769
Provider Name (Legal Business Name): CINNAMON SUE BLOSS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10666 N TORREY PINES RD
LA JOLLA CA
92037-1027
US

IV. Provider business mailing address

FILE 54433
LOS ANGELES CA
90074-4433
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-5737
  • Fax: 858-546-9280
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY23085
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY23085
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: