Healthcare Provider Details

I. General information

NPI: 1821457953
Provider Name (Legal Business Name): LA-TANYA DENISE BLANTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LA-TANYA DENISE BLANTON LCSW

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 AVALON PARK EAST BLVD SUITE 310
ORLANDO FL
32828-9372
US

IV. Provider business mailing address

PO BOX 7635
HAMPTON VA
23666-0635
US

V. Phone/Fax

Practice location:
  • Phone: 407-306-8441
  • Fax: 888-413-8924
Mailing address:
  • Phone: 757-377-5244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11691
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: