Provider Demographics
NPI:1629139696
Name:BLANKS, MARLON LEON (LICENSE CLINICAL SOC)
Entity Type:Individual
Prefix:MR
First Name:MARLON
Middle Name:LEON
Last Name:BLANKS
Suffix:
Gender:M
Credentials:LICENSE CLINICAL SOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 W SAHARA AVE A112
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146
Mailing Address - Country:US
Mailing Address - Phone:702-462-1813
Mailing Address - Fax:
Practice Address - Street 1:6655 W SAHARA AVE STE A112
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-2805
Practice Address - Country:US
Practice Address - Phone:702-462-1813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7112-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1629139696OtherTRICARE WEST
NV1629139696Medicaid