Provider Demographics
NPI:1083815567
Name:BLASKE, SUSAN LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LYNN
Last Name:BLASKE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 TRAVELERS TRL NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2870
Mailing Address - Country:US
Mailing Address - Phone:770-419-3926
Mailing Address - Fax:
Practice Address - Street 1:1007 TRAVELERS TRL NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2870
Practice Address - Country:US
Practice Address - Phone:770-419-3926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO05503111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor