Provider Demographics
NPI:1659415412
Name:BLALOCK, ANDREW CLARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:CLARK
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 LONG BRANCH WAY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-4594
Mailing Address - Country:US
Mailing Address - Phone:404-202-6501
Mailing Address - Fax:404-651-4664
Practice Address - Street 1:4167 ROSWELL RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3715
Practice Address - Country:US
Practice Address - Phone:404-202-6501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0002482103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist