Provider Demographics
NPI:1790217628
Name:BLANKINSHIP, MICHAEL VERNON (BA, AAC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:VERNON
Last Name:BLANKINSHIP
Suffix:
Gender:M
Credentials:BA, AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 W REYNOLDS AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4554
Mailing Address - Country:US
Mailing Address - Phone:360-330-9044
Mailing Address - Fax:360-736-3139
Practice Address - Street 1:28 SW CHEHALIS AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-1933
Practice Address - Country:US
Practice Address - Phone:360-736-2619
Practice Address - Fax:360-740-2770
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG 60505175101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health