Provider Demographics
NPI:1518914480
Name:BLACKBURN, HOLLY L (LCSW)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:L
Last Name:BLACKBURN
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:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:GOOCHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23063-0189
Mailing Address - Country:US
Mailing Address - Phone:804-556-5400
Mailing Address - Fax:804-556-5403
Practice Address - Street 1:3058 RIVER RD W
Practice Address - Street 2:
Practice Address - City:GOOCHLAND
Practice Address - State:VA
Practice Address - Zip Code:23063-3202
Practice Address - Country:US
Practice Address - Phone:804-556-5400
Practice Address - Fax:804-556-5403
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040009521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA100887OtherANTHEM - POWH LOC
VAO89592OtherSENTARA
VI100888OtherHEALTHKEEPERS-GCH LOC
VA100888OtherANTHEM - GCH LOC
VAA932447OtherVALUE OPTIONS
VA100887OtherHEALTHKEEPERS - POWH LOC
VAA932447OtherVALUE OPTIONS