Provider Demographics
NPI:1689242745
Name:BLANKENSHIP, SHAKETHA (PHD, LPC, NCC)
Entity Type:Individual
Prefix:DR
First Name:SHAKETHA
Middle Name:
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:PHD, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 BARRINGTON LN
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-6954
Mailing Address - Country:US
Mailing Address - Phone:404-409-7361
Mailing Address - Fax:
Practice Address - Street 1:2026 BARRINGTON LN
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-6954
Practice Address - Country:US
Practice Address - Phone:404-409-7361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA391660101YS0200X
GALPC008522101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool