Healthcare Provider Details

I. General information

NPI: 1508010182
Provider Name (Legal Business Name): CARLY B BLACKSTONE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 S GLEBE RD SUITE 103
ARLINGTON VA
22204-1655
US

IV. Provider business mailing address

46 S GLEBE RD SUITE 103
ARLINGTON VA
22204-1655
US

V. Phone/Fax

Practice location:
  • Phone: 703-521-6004
  • Fax: 701-521-6342
Mailing address:
  • Phone: 703-521-6004
  • Fax: 701-521-6342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810003993
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: