MEDICARE: ALAN D BLOTCKY PHD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	430	OTHER	AL	LICENSE

General Provider Information

NPI Number	:	1285254755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALAN D BLOTCKY PHD LLC

Provider Business Mailing Address
First Line	:	973 VIRIDIAN WAY
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35226-2810
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	529 BEACON PKWY W STE 107
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35209-3126
Country	:	US
Telephone Number	:	205-912-7171
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALAN BLOTCKY
Credential	:	PHD
Telephone Number	:	205-912-7171

Provider Enumeration Date	:	04/24/2020
Last Update Date	:	04/29/2020

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