Provider Demographics
NPI:1902122815
Name:BLANKENSHIP, KEVIN RANDALL
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:RANDALL
Last Name:BLANKENSHIP
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 1:1024 4TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAFT
Mailing Address - State:CA
Mailing Address - Zip Code:93268
Mailing Address - Country:US
Mailing Address - Phone:661-754-2524
Mailing Address - Fax:661-765-6189
Practice Address - Street 1:1024 4TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:TAFT
Practice Address - State:CA
Practice Address - Zip Code:93268
Practice Address - Country:US
Practice Address - Phone:661-754-2524
Practice Address - Fax:661-765-6189
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health