Provider Demographics
NPI:1922360247
Name:BLALOCK, KRISTY ELEANOR (LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:ELEANOR
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8069 GREEN ORCHARD RD
Mailing Address - Street 2:APT 12
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5115
Mailing Address - Country:US
Mailing Address - Phone:443-223-2193
Mailing Address - Fax:
Practice Address - Street 1:8028 RITCHIE HWY
Practice Address - Street 2:SUITE 308
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-1075
Practice Address - Country:US
Practice Address - Phone:410-761-0725
Practice Address - Fax:410-761-2412
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12860101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health