Basic Information
| Provider Information | |||||||||
| NPI: | 1053750497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKLEDGE | ||||||||
| FirstName: | MORGAN | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1977 N GAREY AVE | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096236651 | ||||||||
| FaxNumber: | 9096230455 | ||||||||
| Practice Location | |||||||||
| Address1: | 6267 VARIEL AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913672512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186570411 | ||||||||
| FaxNumber: | 8186570406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2013 | ||||||||
| LastUpdateDate: | 09/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106H00000X | 78266 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.