Provider Demographics
NPI:1588783146
Name:BLANKENBERG, RICHARD WALTER (PHD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:WALTER
Last Name:BLANKENBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 VALLEY CREST RD
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:08801-3104
Mailing Address - Country:US
Mailing Address - Phone:908-432-5461
Mailing Address - Fax:
Practice Address - Street 1:46 VALLEY CREST RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:NJ
Practice Address - Zip Code:08801-3104
Practice Address - Country:US
Practice Address - Phone:908-432-5461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00354000103T00000X, 103TB0200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities