Healthcare Provider Details

I. General information

NPI: 1467373100
Provider Name (Legal Business Name): MRS. STACIE L BLANKENSHIP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5280 OLD RELIANCE RD
BRYAN TX
77808-1525
US

IV. Provider business mailing address

9661 JINKINS RD
NORTH ZULCH TX
77872-6837
US

V. Phone/Fax

Practice location:
  • Phone: 979-229-7735
  • Fax:
Mailing address:
  • Phone: 979-229-7735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number97866
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: