Provider Demographics
NPI:1053750497
Name:BLACKLEDGE, MORGAN A
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:A
Last Name:BLACKLEDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1977 N GAREY AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2774
Mailing Address - Country:US
Mailing Address - Phone:909-623-6651
Mailing Address - Fax:909-623-0455
Practice Address - Street 1:6267 VARIEL AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-2512
Practice Address - Country:US
Practice Address - Phone:818-657-0411
Practice Address - Fax:818-657-0406
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA78266106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program