Provider Demographics
NPI:1821423245
Name:BLIWISE, DONALD L (PHD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:BLIWISE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 CLIFTON RD NE RM 509
Mailing Address - Street 2:WESLEY WOODS HEALTH CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4021
Mailing Address - Country:US
Mailing Address - Phone:404-728-4751
Mailing Address - Fax:404-712-8145
Practice Address - Street 1:1841 CLIFTON RD NE RM 509
Practice Address - Street 2:WESLEY WOODS HEALTH CENTER
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4021
Practice Address - Country:US
Practice Address - Phone:404-728-4751
Practice Address - Fax:404-712-8145
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1700103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist