Provider Demographics
NPI:1992274914
Name:BLISS, SEBASTIAN JAMES (PHD)
Entity type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:JAMES
Last Name:BLISS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:WHITNEY
Other - Middle Name:MACKENZIE
Other - Last Name:BLISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:940 BELMONT ST BLDG 5
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5596
Mailing Address - Country:US
Mailing Address - Phone:774-826-3510
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST BLDG 5
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:774-826-3510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38389103TC0700X
390200000X
NY023720103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX38389OtherTEXAS BOARD OF EXAMINERS OF PSYCHOLOGISTS