Healthcare Provider Details

I. General information

NPI: 1265953293
Provider Name (Legal Business Name): CHRISTINE M BLALOCK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTINE M PIDDINGTON LCSW

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 SHOREHAM PL STE 100
SAN DIEGO CA
92122-5904
US

IV. Provider business mailing address

PO BOX 84
SOLDOTNA AK
99669-0084
US

V. Phone/Fax

Practice location:
  • Phone: 866-657-6592
  • Fax:
Mailing address:
  • Phone: 909-735-6656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number69521
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: