Provider Demographics
NPI:1104394980
Name:BLANTON, JULIANA (MA)
Entity Type:Individual
Prefix:
First Name:JULIANA
Middle Name:
Last Name:BLANTON
Suffix:
Gender:F
Credentials:MA
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 571097
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-1097
Mailing Address - Country:US
Mailing Address - Phone:336-716-0800
Mailing Address - Fax:336-716-0822
Practice Address - Street 1:403 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3784
Practice Address - Country:US
Practice Address - Phone:336-716-0800
Practice Address - Fax:336-716-0822
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14268101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional