Provider Demographics
NPI:1740339324
Name:BLACKSTON, WILLIAM (LCADC)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:BLACKSTON
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 SUGARWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21221-5449
Mailing Address - Country:US
Mailing Address - Phone:410-686-1272
Mailing Address - Fax:410-298-0835
Practice Address - Street 1:7131 RUTHERFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-2702
Practice Address - Country:US
Practice Address - Phone:410-298-2691
Practice Address - Fax:410-298-0835
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD011538101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)