Healthcare Provider Details

I. General information

NPI: 1194482703
Provider Name (Legal Business Name): BLAKE JAMES CORONADO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 11/18/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2495 W MARCH LN
STOCKTON CA
95207-8251
US

IV. Provider business mailing address

2495 W MARCH LN
STOCKTON CA
95207-8251
US

V. Phone/Fax

Practice location:
  • Phone: 209-271-3218
  • Fax:
Mailing address:
  • Phone: 209-271-3218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: