Healthcare Provider Details

I. General information

NPI: 1619314689
Provider Name (Legal Business Name): PATRICIA ANN BLONDO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MAIN AVE SUITE 6
TILLAMOOK OR
97141-2240
US

IV. Provider business mailing address

855 TONE ROAD
TILLAMOOK OR
97141
US

V. Phone/Fax

Practice location:
  • Phone: 503-801-0369
  • Fax:
Mailing address:
  • Phone: 503-801-0369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL5596
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: