Provider Demographics
NPI:1972572253
Name:BLAESS, DANIEL ROBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ROBERT
Last Name:BLAESS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 COLUMBIA ST UNIT 402
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3455
Mailing Address - Country:US
Mailing Address - Phone:619-804-1669
Mailing Address - Fax:619-804-1669
Practice Address - Street 1:1350 COLUMBIA ST UNIT 402
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3455
Practice Address - Country:US
Practice Address - Phone:619-804-1669
Practice Address - Fax:619-804-1669
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17107103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY17107OtherLICENSE
CAP38303Medicare UPIN
CAW18777Medicare PIN