Healthcare Provider Details

I. General information

NPI: 1053757351
Provider Name (Legal Business Name): TIMOTHY BLANKENBAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TIMOTHY BLANKENBAKER LPC, NCC

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 DIXIE PLZ
NATCHITOCHES LA
71457-5881
US

IV. Provider business mailing address

1000 CHINABERRY DR STE 902
BOSSIER CITY LA
71111-2455
US

V. Phone/Fax

Practice location:
  • Phone: 318-357-9009
  • Fax: 318-357-9008
Mailing address:
  • Phone: 318-459-6795
  • Fax: 318-841-1210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4642
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: