Provider Demographics
NPI:1972150688
Name:BLANE, MARCIA (LPC)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:BLANE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 STOCKBRIDGE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3627
Mailing Address - Country:US
Mailing Address - Phone:678-379-8450
Mailing Address - Fax:678-658-2466
Practice Address - Street 1:118 STOCKBRIDGE RD STE 104
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3627
Practice Address - Country:US
Practice Address - Phone:678-379-8450
Practice Address - Fax:678-658-2466
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011552101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health