Provider Demographics
NPI:1942038278
Name:EZIKE, BLISS (PSYCH TECH)
Entity type:Individual
Prefix:
First Name:BLISS
Middle Name:
Last Name:EZIKE
Suffix:
Gender:M
Credentials:PSYCH TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 EDMONDS RD. BLDG. B
Mailing Address - Street 2:
Mailing Address - City:REDWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94602
Mailing Address - Country:US
Mailing Address - Phone:408-529-0063
Mailing Address - Fax:
Practice Address - Street 1:280 EDMONDS RD. BLDG. B
Practice Address - Street 2:
Practice Address - City:REDWOOD
Practice Address - State:CA
Practice Address - Zip Code:94602
Practice Address - Country:US
Practice Address - Phone:408-529-0063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36055167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician