Provider Demographics
NPI:1275570483
Name:BLANKENBAKER, SUSAN ADELL (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ADELL
Last Name:BLANKENBAKER
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3264 MARTHA CUSTIS DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-2112
Mailing Address - Country:US
Mailing Address - Phone:703-998-5677
Mailing Address - Fax:
Practice Address - Street 1:1355 PICCARD DR
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-4315
Practice Address - Country:US
Practice Address - Phone:301-926-1675
Practice Address - Fax:301-926-4185
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MD115551041C0700X
VA09040053041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD009981P01Medicare PIN