Healthcare Provider Details

I. General information

NPI: 1669648838
Provider Name (Legal Business Name): ASHLEY ALISON BLACKETT M A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 THE CITY DR S
ORANGE CA
92868-3303
US

IV. Provider business mailing address

24 ALLENWOOD LN
ALISO VIEJO CA
92656-2913
US

V. Phone/Fax

Practice location:
  • Phone: 714-615-6378
  • Fax: 714-834-4595
Mailing address:
  • Phone: 714-345-8065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 45769
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 63506
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 51950
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: