Provider Demographics
NPI:1235855115
Name:BLANKENSHIP, BROOKE NAOMI (LCPC)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:NAOMI
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:846 W AINSLIE ST APT RC
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7369
Mailing Address - Country:US
Mailing Address - Phone:219-309-6203
Mailing Address - Fax:
Practice Address - Street 1:5215 N RAVENSWOOD AVE STE 208
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1670
Practice Address - Country:US
Practice Address - Phone:219-309-6203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.014180101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional