Individual
DIANE BLACKISTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
297 INDEPENDENCE BLVD, SUITE 126, VIRGINIA BEACH, VA 23462-2911
(757) 385-0511
(757) 473-5161
Mailing address
289 INDEPENDENCE BLVD, SUITE 312, VIRGINIA BEACH, VA 23462
(757) 385-0687
(757) 493-5456
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
0904004231
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
004945395
VA PREMIER
VA
05
—
004945395
—
VA
01
—
256690
ANTHEM
VA
01
—
O84769
OPTIMA
VA
Enumeration date
09/27/2006
Last updated
07/29/2015
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