Provider Demographics
NPI:1588372072
Name:BLYDEN, MARLENE
Entity type:Individual
Prefix:DR
First Name:MARLENE
Middle Name:
Last Name:BLYDEN
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:PO BOX 674
Mailing Address - Street 2:
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875-0600
Mailing Address - Country:US
Mailing Address - Phone:804-220-1650
Mailing Address - Fax:
Practice Address - Street 1:6032 CHINQUAPIN CIR
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE, VA
Practice Address - State:VA
Practice Address - Zip Code:23875
Practice Address - Country:US
Practice Address - Phone:804-220-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701013361101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional