Provider Demographics
NPI:1023494697
Name:BLONDEAU, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BLONDEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2556 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3116 MAPLE DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2608
Practice Address - Country:US
Practice Address - Phone:718-909-0019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC004562101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional