Provider Demographics
NPI:1255977450
Name:BLASSINGALE, COREY
Entity type:Individual
Prefix:MR
First Name:COREY
Middle Name:
Last Name:BLASSINGALE
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 1:2312 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-4405
Mailing Address - Country:US
Mailing Address - Phone:215-880-2949
Mailing Address - Fax:
Practice Address - Street 1:99 PASSMORE DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-1548
Practice Address - Country:US
Practice Address - Phone:302-478-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC-0000942101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health