Provider Demographics
NPI:1457008930
Name:BLASINGAME, AMY (LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BLASINGAME
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 BLACKBURN ST APT 2406
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2209
Mailing Address - Country:US
Mailing Address - Phone:469-705-1327
Mailing Address - Fax:
Practice Address - Street 1:1505 W JEFFERSON ST STE 155
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2223
Practice Address - Country:US
Practice Address - Phone:214-980-1397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69099101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty