Provider Demographics
NPI:1144503335
Name:COWPERTHWAITE, BLAIR
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:
Last Name:COWPERTHWAITE
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 1:5674 STONERIDGE DR STE 207
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-8592
Mailing Address - Country:US
Mailing Address - Phone:925-520-0005
Mailing Address - Fax:
Practice Address - Street 1:714 MAIN ST APT A
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-1121
Practice Address - Country:US
Practice Address - Phone:510-559-0148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA119151104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health