Provider Demographics
NPI:1386320984
Name:BLACKSTOCK, CASSONDRA
Entity type:Individual
Prefix:
First Name:CASSONDRA
Middle Name:
Last Name:BLACKSTOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16812 WARREN CREST CT
Mailing Address - Street 2:
Mailing Address - City:MOSELEY
Mailing Address - State:VA
Mailing Address - Zip Code:23120-2315
Mailing Address - Country:US
Mailing Address - Phone:804-835-8970
Mailing Address - Fax:
Practice Address - Street 1:16812 WARREN CREST CT
Practice Address - Street 2:
Practice Address - City:MOSELEY
Practice Address - State:VA
Practice Address - Zip Code:23120-2315
Practice Address - Country:US
Practice Address - Phone:804-835-8970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health