Provider Demographics
NPI:1104652957
Name:BLALOCK, MARINA PETINOU (LMFT)
Entity type:Individual
Prefix:MRS
First Name:MARINA
Middle Name:PETINOU
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CROW CANYON CT STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1985
Mailing Address - Country:US
Mailing Address - Phone:925-820-8447
Mailing Address - Fax:
Practice Address - Street 1:8 CROW CANYON CT STE 207
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1985
Practice Address - Country:US
Practice Address - Phone:925-820-8447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA148674106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist