Basic Information
| Provider Information | |||||||||
| NPI: | 1053757351 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANKENBAKER | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | BLANKENBAKER | ||||||||
| OtherFirstName: | TIMOTHY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | LPC, NCC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 CHINABERRY DR STE 902 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184596795 | ||||||||
| FaxNumber: | 3188411210 | ||||||||
| Practice Location | |||||||||
| Address1: | 430 DIXIE PLZ | ||||||||
| Address2: | |||||||||
| City: | NATCHITOCHES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714575881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183579009 | ||||||||
| FaxNumber: | 3183579008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2013 | ||||||||
| LastUpdateDate: | 12/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 4642 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.