Healthcare Provider Details

I. General information

NPI: 1386749869
Provider Name (Legal Business Name): MARYJO BLAIR L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HERITAGE WAY NE STE 302
LEESBURG VA
20176-4544
US

IV. Provider business mailing address

42794 OATYER CT
BROADLANDS VA
20148-5000
US

V. Phone/Fax

Practice location:
  • Phone: 703-771-5176
  • Fax: 703-777-0170
Mailing address:
  • Phone: 703-724-3594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904002474
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: