Provider Demographics
NPI:1033654181
Name:BLAYLOCK, VICTORIA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 N KENMORE AVE
Mailing Address - Street 2:APT B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4835 N KENMORE AVE
Practice Address - Street 2:APT B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3727
Practice Address - Country:US
Practice Address - Phone:773-993-2770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0189411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical