Provider Demographics
NPI:1932887015
Name:BLALOCK, KIRSTIN LEIGH
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:LEIGH
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 1:108 OAKLAND CT
Mailing Address - Street 2:
Mailing Address - City:VALDESE
Mailing Address - State:NC
Mailing Address - Zip Code:28690-8709
Mailing Address - Country:US
Mailing Address - Phone:828-390-4470
Mailing Address - Fax:
Practice Address - Street 1:4750 COLLEGIATE DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-1000
Practice Address - Country:US
Practice Address - Phone:850-770-2331
Practice Address - Fax:850-770-2072
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22-233110106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician