Provider Demographics
NPI:1306484316
Name:BLOUNT, MARY JANE (MFT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:GLOWACKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:406 SUNRISE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4106
Mailing Address - Country:US
Mailing Address - Phone:530-470-2409
Mailing Address - Fax:
Practice Address - Street 1:10121 PINE AVE
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4856
Practice Address - Country:US
Practice Address - Phone:530-470-2409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT38077101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor