Provider Demographics
NPI:1083937874
Name:BLASKO, LYNDA SHANE (PHD)
Entity Type:Individual
Prefix:MRS
First Name:LYNDA
Middle Name:SHANE
Last Name:BLASKO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 OAKLAWN AVENUE NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319
Mailing Address - Country:US
Mailing Address - Phone:404-908-1773
Mailing Address - Fax:
Practice Address - Street 1:1409 NORTH HIGHLAND AVENUE
Practice Address - Street 2:SUITE J
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306
Practice Address - Country:US
Practice Address - Phone:404-908-1773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
GA004067103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling