Provider Demographics
NPI:1124836465
Name:BLOMGREN, TANYA (MA, AMFT)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:BLOMGREN
Suffix:
Gender:F
Credentials:MA, AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1734 W SHAW AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3416
Mailing Address - Country:US
Mailing Address - Phone:559-439-5920
Mailing Address - Fax:
Practice Address - Street 1:1734 W SHAW AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3416
Practice Address - Country:US
Practice Address - Phone:559-439-5920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT147828106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist