Basic Information
| Provider Information | |||||||||
| NPI: | 1487632980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOUNT | ||||||||
| FirstName: | TALISA | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9371 ALDERBURY ST | ||||||||
| Address2: | |||||||||
| City: | CYPRESS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906302806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149952128 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1301 W PROVIDENCE AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146394990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AU2153 | CA | X | Speech, Language and Hearing Service Providers | Audiologist | 231HA2400X | HA4112 | CA | X | Speech, Language and Hearing Service Providers | Audiologist | Assistive Technology Practitioner |
ID Information
| ID | Type | State | Issuer | Description | AU0021530 | 05 | CA | MEDICAID |