Provider Demographics
NPI:1942792049
Name:BLENKUSH, NATHAN (LP)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:BLENKUSH
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 OAKHILL AVE
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-6209
Mailing Address - Country:US
Mailing Address - Phone:178-195-3282
Mailing Address - Fax:
Practice Address - Street 1:250 TURNPIKE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2359
Practice Address - Country:US
Practice Address - Phone:781-828-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10814103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist