Provider Demographics
NPI:1891442703
Name:BLACKSHEAR, MINDIE M (LPC)
Entity Type:Individual
Prefix:
First Name:MINDIE
Middle Name:M
Last Name:BLACKSHEAR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 SCOGGINS DR
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-5354
Mailing Address - Country:US
Mailing Address - Phone:706-894-3712
Mailing Address - Fax:
Practice Address - Street 1:196 SCOGGINS DR
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-5354
Practice Address - Country:US
Practice Address - Phone:706-894-3712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012752101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty