Provider Demographics
NPI:1083468177
Name:BLACKSTOCK, ANDRIA
Entity Type:Individual
Prefix:MRS
First Name:ANDRIA
Middle Name:
Last Name:BLACKSTOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 JOHN B GORDON SPUR
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-6528
Mailing Address - Country:US
Mailing Address - Phone:770-229-3407
Mailing Address - Fax:
Practice Address - Street 1:103 JOHN B GORDON SPUR
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-6528
Practice Address - Country:US
Practice Address - Phone:770-229-3407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA619834225C00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor