Provider Demographics
NPI:1811552110
Name:BLANKENSHIP, BREANNE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3290
Mailing Address - Country:US
Mailing Address - Phone:219-326-1234
Mailing Address - Fax:
Practice Address - Street 1:45 N WHITTAKER ST STE 204
Practice Address - Street 2:
Practice Address - City:NEW BUFFALO
Practice Address - State:MI
Practice Address - Zip Code:49117-1173
Practice Address - Country:US
Practice Address - Phone:269-235-9083
Practice Address - Fax:269-235-9821
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006544A235Z00000X
MI7101008565235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist