Provider Demographics
NPI:1780321331
Name:BLACKSTONE, WILLIAM JAMAL
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JAMAL
Last Name:BLACKSTONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5429 VARNUM STREET
Mailing Address - Street 2:
Mailing Address - City:BLADENSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20710
Mailing Address - Country:US
Mailing Address - Phone:240-972-4414
Mailing Address - Fax:
Practice Address - Street 1:5429 VARNUM STREET
Practice Address - Street 2:
Practice Address - City:BLADENSBURG
Practice Address - State:MD
Practice Address - Zip Code:20710
Practice Address - Country:US
Practice Address - Phone:240-972-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst