Provider Demographics
NPI:1942832993
Name:BLALOCK, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 FOREST HILL RD APT 612
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4834
Mailing Address - Country:US
Mailing Address - Phone:678-914-7293
Mailing Address - Fax:
Practice Address - Street 1:444 FOREST HILL RD APT 612
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4834
Practice Address - Country:US
Practice Address - Phone:888-451-8912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty