Provider Demographics
NPI:1063577229
Name:BLITCHINGTON, WESLEY PETER (PHD)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:PETER
Last Name:BLITCHINGTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:W.
Other - Middle Name:PETER
Other - Last Name:BLITCHINGTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2909 W STATE ROAD 434
Mailing Address - Street 2:SUITE 111
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4459
Mailing Address - Country:US
Mailing Address - Phone:407-774-0557
Mailing Address - Fax:407-774-9329
Practice Address - Street 1:2909 W STATE ROAD 434
Practice Address - Street 2:SUITE 111
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4459
Practice Address - Country:US
Practice Address - Phone:407-774-0557
Practice Address - Fax:407-774-9329
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3223103T00000X
FLPY 3223103TB0200X, 103TC0700X, 103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6126818OtherUNITED BEHAVIORAL HEALTH
FL593016832OtherTRICARE
FL63893OtherCIGNA
FL75237OtherBCBS FL
FL053110OtherVALUE OPTIONS
FL75237OtherMEDICARE P10
FL593016832OtherTRICARE