Provider Demographics
NPI:1386749869
Name:BLAIR, MARYJO (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARYJO
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42794 OATYER CT
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-5000
Mailing Address - Country:US
Mailing Address - Phone:703-724-3594
Mailing Address - Fax:
Practice Address - Street 1:102 HERITAGE WAY NE STE 302
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-4544
Practice Address - Country:US
Practice Address - Phone:703-771-5176
Practice Address - Fax:703-777-0170
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040024741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA290476OtherANTHEM
VA293877OtherAMERIGROUP
VA290477OtherANTHEM