Provider Demographics
NPI:1790196996
Name:BOARDMAN-BLOCKER, DOROTHY EUNICE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:EUNICE
Last Name:BOARDMAN-BLOCKER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:DOROTHY
Other - Middle Name:BOARDMAN
Other - Last Name:BLOCKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:194 BEAR MILL RD
Mailing Address - Street 2:
Mailing Address - City:CRAWFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30630-2708
Mailing Address - Country:US
Mailing Address - Phone:706-614-5923
Mailing Address - Fax:706-383-7524
Practice Address - Street 1:194 BEAR MILL RD
Practice Address - Street 2:
Practice Address - City:CRAWFORD
Practice Address - State:GA
Practice Address - Zip Code:30630-2708
Practice Address - Country:US
Practice Address - Phone:706-614-5923
Practice Address - Fax:706-383-7524
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-11
Last Update Date:2014-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC0004212101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional