Provider Demographics
NPI:1508675869
Name:BLACKFORD, BRYCE MATTHEW (LGPC)
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:MATTHEW
Last Name:BLACKFORD
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 TEAK LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-2041
Mailing Address - Country:US
Mailing Address - Phone:240-274-1463
Mailing Address - Fax:
Practice Address - Street 1:3003 TEAK LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-2041
Practice Address - Country:US
Practice Address - Phone:240-274-1463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15994101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional