Provider Demographics
NPI:1871824375
Name:BLASSINGAME, GAYLEN (GAYLEN BLASSINGAME)
Entity Type:Individual
Prefix:
First Name:GAYLEN
Middle Name:
Last Name:BLASSINGAME
Suffix:
Gender:F
Credentials:GAYLEN BLASSINGAME
Other - Prefix:
Other - First Name:GAYLEN
Other - Middle Name:
Other - Last Name:BLASSINGAME
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:GAYLEN BLASSINGAME
Mailing Address - Street 1:4307 BROOKHOLLOW DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-7603
Mailing Address - Country:US
Mailing Address - Phone:817-565-2389
Mailing Address - Fax:
Practice Address - Street 1:4307 BROOKHOLLOW DRIVE
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-7603
Practice Address - Country:US
Practice Address - Phone:817-565-2389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32173101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional