Provider Demographics
NPI:1245270909
Name:BLANTON, MARIELLEN E (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARIELLEN
Middle Name:E
Last Name:BLANTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2816 W GIBBS RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23457-1067
Mailing Address - Country:US
Mailing Address - Phone:757-242-9988
Mailing Address - Fax:
Practice Address - Street 1:79 E WINDSOR BLVD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VA
Practice Address - Zip Code:23487-9410
Practice Address - Country:US
Practice Address - Phone:757-242-9988
Practice Address - Fax:757-242-3647
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710101448101YA0400X
VA09040060991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA194059OtherBSVA
VA2143183OtherMAMSI
248016OtherANTHEM BCBS
VAO88709MOtherSENTARA MENTAL HEALTH
1322073OtherCOMPSYCH
268230OtherCOMPSYCH
VA374444OtherCHAMPUS
VA374444OtherCHAMPUS
1322073OtherCOMPSYCH