Provider Demographics
NPI:1285266924
Name:BLANKENSHIP, THERESA A (BCABA, LABA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:BCABA, LABA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:A
Other - Last Name:JERNIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9038 CROSS PARK DR STE 105
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4720
Mailing Address - Country:US
Mailing Address - Phone:865-394-6612
Mailing Address - Fax:865-315-7014
Practice Address - Street 1:9038 CROSS PARK DR STE 105
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4720
Practice Address - Country:US
Practice Address - Phone:865-394-6612
Practice Address - Fax:865-315-7014
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-20-111054106S00000X
TNLABA36106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0-22-13918OtherBACB
TNRBT-20-111054OtherBACB