Healthcare Provider Details

I. General information

NPI: 1043139371
Provider Name (Legal Business Name): GREGORY BLALOCK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2026
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3623 CALVIN DR
COLUMBUS GA
31904-7915
US

IV. Provider business mailing address

211 BLUEBIRD TRL
FORTSON GA
31808-7025
US

V. Phone/Fax

Practice location:
  • Phone: 706-940-5100
  • Fax:
Mailing address:
  • Phone: 706-566-9580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-549344
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: