Provider Demographics
NPI:1841201852
Name:BLACKWELL, MARY CLAYTON (LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CLAYTON
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 CLUB DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-2556
Mailing Address - Country:US
Mailing Address - Phone:434-384-8470
Mailing Address - Fax:
Practice Address - Street 1:150 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-2010
Practice Address - Country:US
Practice Address - Phone:434-384-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002858101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA164584OtherANTHEM
VA082329MOtherOPTIMA/SENTARA