Healthcare Provider Details

I. General information

NPI: 1053933796
Provider Name (Legal Business Name): DIANE BLACKMON LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2020
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W REDWOOD ST STE 202
BALTIMORE MD
21201-1708
US

IV. Provider business mailing address

306 W REDWOOD ST STE 202
BALTIMORE MD
21201-1708
US

V. Phone/Fax

Practice location:
  • Phone: 301-276-4116
  • Fax:
Mailing address:
  • Phone: 301-276-4116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC018447
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26801
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: