Provider Demographics
NPI:1871801803
Name:BLALACK, CARLY SANTOS (LCSW, PPS)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:SANTOS
Last Name:BLALACK
Suffix:
Gender:F
Credentials:LCSW, PPS
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:ELISABETH
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3835 N FREEWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1954
Mailing Address - Country:US
Mailing Address - Phone:916-576-7900
Mailing Address - Fax:
Practice Address - Street 1:4700 SPRING ST STE 220
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-0274
Practice Address - Country:US
Practice Address - Phone:619-667-3380
Practice Address - Fax:619-667-0815
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical