Provider Demographics
NPI:1568655199
Name:BLAYLOCK, CHRISTIE LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:LEE
Last Name:BLAYLOCK
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 1:14325 JEFFRIES PL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-4359
Mailing Address - Country:US
Mailing Address - Phone:804-419-4122
Mailing Address - Fax:804-520-5650
Practice Address - Street 1:14325 JEFFRIES PL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-4359
Practice Address - Country:US
Practice Address - Phone:804-409-2353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040033161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical