Provider Demographics
NPI:1336492826
Name:BLANN, MISTY (ASW)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:BLANN
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 WILLOW ST STE 6A
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-4279
Mailing Address - Country:US
Mailing Address - Phone:812-882-0894
Mailing Address - Fax:
Practice Address - Street 1:1813 WILLOW ST STE 6A
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-4279
Practice Address - Country:US
Practice Address - Phone:812-882-0894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-21
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040088191041C0700X
IN34007530A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical