Provider Demographics
NPI:1194422642
Name:BLASSINGAME, COURTNEY NICOLE (LMSW)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:BLASSINGAME
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 LARK ST APT 13
Mailing Address - Street 2:
Mailing Address - City:TATUM
Mailing Address - State:TX
Mailing Address - Zip Code:75691-1757
Mailing Address - Country:US
Mailing Address - Phone:903-646-7069
Mailing Address - Fax:
Practice Address - Street 1:1305 LARK ST APT 13
Practice Address - Street 2:
Practice Address - City:TATUM
Practice Address - State:TX
Practice Address - Zip Code:75691-1757
Practice Address - Country:US
Practice Address - Phone:903-646-7069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104375104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker