Provider Demographics
NPI:1699941369
Name:BLANCK, TICIA ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:TICIA
Middle Name:ANN
Last Name:BLANCK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 REDONDO CT
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-2931
Mailing Address - Country:US
Mailing Address - Phone:541-490-7045
Mailing Address - Fax:805-544-1412
Practice Address - Street 1:#70 ESTES AVE.
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672
Practice Address - Country:US
Practice Address - Phone:541-490-7045
Practice Address - Fax:805-544-1412
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003284103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical