Provider Demographics
NPI:1609078500
Name:BLANKENSHIP, ROY ALLN (LPC,LMFT,CCADC, CSAT)
Entity type:Individual
Prefix:MR
First Name:ROY
Middle Name:ALLN
Last Name:BLANKENSHIP
Suffix:
Gender:M
Credentials:LPC,LMFT,CCADC, CSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426 OLDE FORGE LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-1553
Mailing Address - Country:US
Mailing Address - Phone:678-516-6902
Mailing Address - Fax:678-391-5969
Practice Address - Street 1:1301 SHILOH ROAD
Practice Address - Street 2:SUITE 840
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:678-516-6902
Practice Address - Fax:678-391-5969
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-03
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
C0082101YA0400X
489101YP1600X
106H00000X
GALMFT001409106H00000X
GALPC007769101YP2500X
GAAPC002945101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist