Provider Demographics
NPI:1780251363
Name:BLASZCZYK, TINA MARIA (LCSW-A)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIA
Last Name:BLASZCZYK
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 WALKERTOWN GUTHRIE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-6435
Mailing Address - Country:US
Mailing Address - Phone:313-587-2633
Mailing Address - Fax:
Practice Address - Street 1:4680 BROWNSBORO RD RM A2
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3428
Practice Address - Country:US
Practice Address - Phone:336-261-6440
Practice Address - Fax:336-232-1436
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor