Provider Demographics
NPI:1679729412
Name:BLAKEMAN, REBECCA S (PHD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:S
Last Name:BLAKEMAN
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 1:4643 RABUN DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-5827
Mailing Address - Country:US
Mailing Address - Phone:404-310-1161
Mailing Address - Fax:
Practice Address - Street 1:5833 STEWART PKWY STE 203
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-6934
Practice Address - Country:US
Practice Address - Phone:404-310-1161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002757103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent