Provider Demographics
NPI:1245003870
Name:BLAYLOCK, MARANDA DARLINE (RBT)
Entity type:Individual
Prefix:
First Name:MARANDA
Middle Name:DARLINE
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 S YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-1958
Mailing Address - Country:US
Mailing Address - Phone:931-260-2024
Mailing Address - Fax:
Practice Address - Street 1:88 PANTHER DR
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583-2601
Practice Address - Country:US
Practice Address - Phone:931-738-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician