Basic Information
| Provider Information | |||||||||
| NPI: | 1992955710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | KRISTOPHER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3580 WILSHIRE BLVD | ||||||||
| Address2: | 8TH FLOOR | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900102501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136375000 | ||||||||
| FaxNumber: | 2134272100 | ||||||||
| Practice Location | |||||||||
| Address1: | 3580 WILSHIRE BLVD | ||||||||
| Address2: | 8TH FLOOR | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900102501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136375000 | ||||||||
| FaxNumber: | 2134272100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2008 | ||||||||
| LastUpdateDate: | 09/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 50890 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.