Provider Demographics
NPI:1417048372
Name:BLACKISTON, DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BLACKISTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 INDEPENDENCE BLVD
Mailing Address - Street 2:SUITE 312
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462
Mailing Address - Country:US
Mailing Address - Phone:757-385-0687
Mailing Address - Fax:757-493-5456
Practice Address - Street 1:297 INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 126
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-2911
Practice Address - Country:US
Practice Address - Phone:757-385-0511
Practice Address - Fax:757-473-5161
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040042311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA256690OtherANTHEM
VA004945395Medicaid
VAO84769OtherOPTIMA
VA004945395OtherVA PREMIER
VA004945395OtherVA PREMIER
VAO84769OtherOPTIMA