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General NPI Number Information
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NPI Number | 1467226373
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Entity Type | Individual
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Provider Name | BLAINE ROBERT LEE PMHNP-BC
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Gender | Male
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Dates
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Enumeration Date | 11/10/2023
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Last Update Date | 04/24/2024
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Provider Practice Location Address
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Address Line | 431 W LAMBERT RD STE 310
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City | BREA
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State | CA
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Zip | 92821-3918
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Country | US
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Telephone | 714-325-7110
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Fax | 949-346-4026
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Provider Business Mailing Address
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Address Line | 2375 E IMPERIAL HWY # 1137
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City | BREA
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State | CA
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Zip | 92821-6112
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 95027984
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License Number State | CA
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