Basic Information
| Provider Information | |||||||||
| NPI: | 1417341694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANTON | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1358 E KINGSLEY ST STE B | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658047222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178811580 | ||||||||
| FaxNumber: | 4178817004 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 E BRADFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658044264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177615000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2015 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 2015016665 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.