Provider Demographics
NPI:1902462641
Name:BLAYLOCK, KELLY ALYSSA
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ALYSSA
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SILVERADO ST STE 300
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-4234
Mailing Address - Country:US
Mailing Address - Phone:619-940-7441
Mailing Address - Fax:
Practice Address - Street 1:5088 PACIFICA DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-1502
Practice Address - Country:US
Practice Address - Phone:619-940-7441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health