Healthcare Provider Details

I. General information

NPI: 1720117468
Provider Name (Legal Business Name): TIMOTHY GEORGE BLATT LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 FAIR OAKS AVE
SOUTH PASADENA CA
91030-2630
US

IV. Provider business mailing address

2753 LA CUESTA DR
LOS ANGELES CA
90046-1338
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 323-874-4765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC28273
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: