Provider Demographics
NPI:1194124289
Name:BLANK, DANIEL (MED, LPC)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:BLANK
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 WOODLANE RD
Mailing Address - Street 2:SUIT 301
Mailing Address - City:WESTAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-3832
Mailing Address - Country:US
Mailing Address - Phone:609-288-3056
Mailing Address - Fax:
Practice Address - Street 1:795 WOODLANE RD
Practice Address - Street 2:SUIT 301
Practice Address - City:WESTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-3832
Practice Address - Country:US
Practice Address - Phone:609-288-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00447900101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ37PC00447900OtherBOARD OF MARRAIGE AND FAMILY THERAPY OF NEW JERSERY