Provider Demographics
NPI:1194239251
Name:ELIZABETH BLALOCK, LCSW,PA
Entity type:Organization
Organization Name:ELIZABETH BLALOCK, LCSW,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:BLALOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:704-365-7777
Mailing Address - Street 1:6809 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4195
Mailing Address - Country:US
Mailing Address - Phone:704-365-7777
Mailing Address - Fax:704-554-9682
Practice Address - Street 1:6809 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-4195
Practice Address - Country:US
Practice Address - Phone:704-365-7777
Practice Address - Fax:704-554-9682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1982641114OtherNPI