Provider Demographics
NPI:1508456427
Name:BLANTON, ASHLEY KEITH (LPC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:KEITH
Last Name:BLANTON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 S LUMPKIN ST APT M228
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-1532
Mailing Address - Country:US
Mailing Address - Phone:912-381-3179
Mailing Address - Fax:
Practice Address - Street 1:1091 PARK DR STE B
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-2014
Practice Address - Country:US
Practice Address - Phone:706-546-7550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011952101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional