Healthcare Provider Details

I. General information

NPI: 1215593959
Provider Name (Legal Business Name): ADAM BLEVISS WHITLATCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W WALNUT ST STE 375
PASADENA CA
91124-0001
US

IV. Provider business mailing address

100 W WALNUT ST STE 375
PASADENA CA
91124-0001
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 626-397-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number90040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: