Healthcare Provider Details

I. General information

NPI: 1497661763
Provider Name (Legal Business Name): NATHAN BLAKE PPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 26TH ST
SAN DIEGO CA
92102-3026
US

IV. Provider business mailing address

2035 SAINT ANDREWS WAY
HAWTHORNE CA
90250-3376
US

V. Phone/Fax

Practice location:
  • Phone: 619-780-0400
  • Fax:
Mailing address:
  • Phone: 818-445-1914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number230284816
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: