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General NPI Number Information
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NPI Number | 1053933796
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Entity Type | Individual
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Provider Name | DIANE BLACKMON LCSW-C
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Gender | Female
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Dates
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Enumeration Date | 05/16/2020
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Last Update Date | 09/15/2023
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Provider Practice Location Address
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Address Line | 5000 THAYER CTR STE C
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City | OAKLAND
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State | MD
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Zip | 21550-1139
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Country | US
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Telephone | 301-276-4116
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Fax |
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Provider Business Mailing Address
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Address Line | 10308 GLEN VISTA DR
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City | DALLAS
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State | TX
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Zip | 75217-3582
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Country | US
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Telephone | 240-863-8884
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 26801
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License Number State | MD
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