Provider Demographics
NPI:1780063941
Name:BLANKS, TERRY CORNELIUS
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:CORNELIUS
Last Name:BLANKS
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 1:9548 S FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1406
Mailing Address - Country:US
Mailing Address - Phone:773-663-9676
Mailing Address - Fax:
Practice Address - Street 1:9548 S FOREST AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1406
Practice Address - Country:US
Practice Address - Phone:773-663-9676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178001564103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical