Provider Demographics
NPI:1659941755
Name:BLANDON, DIANA D (MSW,QMHP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:D
Last Name:BLANDON
Suffix:
Gender:F
Credentials:MSW,QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3658
Mailing Address - Country:US
Mailing Address - Phone:540-303-1217
Mailing Address - Fax:
Practice Address - Street 1:4000 GENESEE PL STE 101
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8302
Practice Address - Country:US
Practice Address - Phone:571-659-0056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0733003450251B00000X
VA09060112401041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No251B00000XAgenciesCase Management
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty