Provider Demographics
NPI:1871051326
Name:BLANTON, ELIZABETH A (LCSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:BLANTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 LEONARDS LN
Mailing Address - Street 2:
Mailing Address - City:TROUT RUN
Mailing Address - State:PA
Mailing Address - Zip Code:17771-9242
Mailing Address - Country:US
Mailing Address - Phone:570-772-2559
Mailing Address - Fax:
Practice Address - Street 1:48 EAST AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1714
Practice Address - Country:US
Practice Address - Phone:570-724-3549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACWO22322101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health