Gary A Blank, PH.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PSY3303 Issued in CA

Practice address

2455 Bennett Valley Rd
Suite 208B
Santa Rosa, CA 95404-5663

Phone

(707) 526-2525

Fax

(707) 526-2593

NPI assigned

Apr 11, 2007

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Psychologist

Education

Other, 1967

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Performance Psychology Center

  • Mental Health Counselor
  • Santa Rosa, CA
  • NPI 1982485413
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176249600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1316160906",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2455 BENNETT VALLEY RD",
            "address_2": "SUITE 208B",
            "city": "SANTA ROSA",
            "state": "CA",
            "postal_code": "954045663",
            "telephone_number": "707-526-2525",
            "fax_number": "707-526-2593"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2455 BENNETT VALLEY RD",
            "address_2": "SUITE 208B",
            "city": "SANTA ROSA",
            "state": "CA",
            "postal_code": "954045663",
            "telephone_number": "707-526-2525",
            "fax_number": "707-526-2593"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLANK",
        "first_name": "GARY",
        "middle_name": "A",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-04-11",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CA",
            "license": "PSY3303",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Eylin Margarita Blake, AMFT
• Katie Blake, LCSW
• Lizabeth Donava Blanchard, PT
• Aleli Blanco, RN, PHN
• Richard D. Bland, MD
• Jillian M Blank
• Morkeh Blay-Tofey, MD, MBA
• BLC Lodge at Paulin LP (Brookdale Paulin Creek)
• Thomas Perry Blechel, PT
• Jennifer Danielle Bleck

• Clinical Psychologist in Santa Rosa, CA
• Providers in Santa Rosa, CA by specialty
• Clinical Psychologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.