Provider Demographics
NPI:1003547209
Name:BLAKEMORE, CAROLYN FOX
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:FOX
Last Name:BLAKEMORE
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 1:2230 W CHAPMAN AVE # 209
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2316
Mailing Address - Country:US
Mailing Address - Phone:323-657-0270
Mailing Address - Fax:
Practice Address - Street 1:2230 W CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2316
Practice Address - Country:US
Practice Address - Phone:805-323-0270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137793106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist