Provider Demographics
NPI:1104969104
Name:BLANTON, JUDITH A (MED)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:BLANTON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 465
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-0465
Mailing Address - Country:US
Mailing Address - Phone:502-348-7722
Mailing Address - Fax:
Practice Address - Street 1:6670 BELLWOOD RD.
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-4000
Practice Address - Country:US
Practice Address - Phone:502-348-7722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0120106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist