Provider Demographics
NPI:1831337807
Name:BLALARK, AVA LAVON (LCSW)
Entity type:Individual
Prefix:MRS
First Name:AVA
Middle Name:LAVON
Last Name:BLALARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:AVA
Other - Middle Name:LAVON
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:18W101 STANDISH LN
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3644
Mailing Address - Country:US
Mailing Address - Phone:773-469-5499
Mailing Address - Fax:
Practice Address - Street 1:18W101 STANDISH LN
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-3644
Practice Address - Country:US
Practice Address - Phone:773-469-5499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL22467751041S0200X
IL149.0175741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical