Provider Demographics
NPI:1346679081
Name:BLANTON LACY, MONICA (PHD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:BLANTON LACY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SUMMERTIME DR
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1591
Mailing Address - Country:US
Mailing Address - Phone:301-502-8690
Mailing Address - Fax:
Practice Address - Street 1:701 SUMMERTIME DR
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1591
Practice Address - Country:US
Practice Address - Phone:301-502-8690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool