MEDICARE: THERESA BLAIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	ASW112487	CA

General Provider Information

NPI Number	:	1346001484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA BLAIN

Provider Business Mailing Address
First Line	:	4221 WILSHIRE BLVD STE 230
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3554
Country	:	US
Telephone Number	:	213-505-4307
Fax Number	:

Provider Business Practice Location Address
First Line	:	12190 CUYAMACA COLLEGE DR E UNIT 1204
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92019-4356
Country	:	US
Telephone Number	:	703-386-6283
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2024
Last Update Date	:	01/16/2024

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Directions to “ THERESA BLAIN ” Practice Location

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