Provider Demographics
NPI:1124736434
Name:CORDOVA, BLAINE
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13824 WINDING PATH LN
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77378-1005
Mailing Address - Country:US
Mailing Address - Phone:713-870-5516
Mailing Address - Fax:
Practice Address - Street 1:26010 OAK RIDGE DR STE 107
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-1972
Practice Address - Country:US
Practice Address - Phone:281-815-0899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39578101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor