Provider Demographics
NPI:1982641114
Name:BLALOCK, ELIZABETH S (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:S
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6809 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3336
Mailing Address - Country:US
Mailing Address - Phone:704-365-7777
Mailing Address - Fax:704-554-9682
Practice Address - Street 1:6809 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3336
Practice Address - Country:US
Practice Address - Phone:704-365-7777
Practice Address - Fax:704-554-9682
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0035521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical