Basic Information
| Provider Information | |||||||||
| NPI: | 1467893693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLASKOVICH | ||||||||
| FirstName: | DAGNY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HARVEY WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950602103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314258132 | ||||||||
| FaxNumber: | 8314254581 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HARVEY WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950602103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314258132 | ||||||||
| FaxNumber: | 8314254581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2013 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | ASW61497 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCSW88191 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.