Healthcare Provider Details

I. General information

NPI: 1629807292
Provider Name (Legal Business Name): JOANNE MARIE BLOUNT PPS, LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/31/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9550 RONALD E MCNAIR WAY
STOCKTON CA
95210-2800
US

IV. Provider business mailing address

17706 E BENTLEY CT
LINDEN CA
95236-9647
US

V. Phone/Fax

Practice location:
  • Phone: 209-953-9245
  • Fax:
Mailing address:
  • Phone: 209-401-5275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLEP4204
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: