Provider Demographics
NPI:1316160906
Name:BLANK, GARY A (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:BLANK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2455 BENNETT VALLEY RD
Mailing Address - Street 2:SUITE 208B
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5663
Mailing Address - Country:US
Mailing Address - Phone:707-526-2525
Mailing Address - Fax:707-526-2593
Practice Address - Street 1:2455 BENNETT VALLEY RD
Practice Address - Street 2:SUITE 208B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5663
Practice Address - Country:US
Practice Address - Phone:707-526-2525
Practice Address - Fax:707-526-2593
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY3303103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL33031Medicare ID - Type Unspecified