| Doctor Name: | DR. TICIA ANN BLANCK |
| NPI Number: | 1699941369 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PSY.D. |
| License Number: | PY00003284 |
| Business Practice Address: | #70 Estes Ave. White Salmon, WA - 98672 |
| Business Phone Number: | 5414907045 |
| Business Fax Number: | 8055441412 |
| Mailing Address: | 600 Redondo Ct, GROVER BEACH |
| State: | CA |
| Postal Code: | 934332931 |
| Phone Number: | 5414907045 |
| Fax Number: | 8055441412 |
| NPI Enumeration Date: | 05/02/2008 |
| NPI Last Update Date: | 05/02/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | PY00003284 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |