Diane Blackiston, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

0904004231 Issued in VA

Practice address

297 Independence Blvd
Suite 126
Virginia Beach, VA 23462-2911

Phone

(757) 385-0511

Fax

(757) 473-5161

NPI assigned

Sep 27, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 4

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159315200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1438128000000",
    "number": "1417048372",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "289 INDEPENDENCE BLVD",
            "address_2": "SUITE 312",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "23462",
            "telephone_number": "757-385-0687",
            "fax_number": "757-493-5456"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "297 INDEPENDENCE BLVD",
            "address_2": "SUITE 126",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "234622911",
            "telephone_number": "757-385-0511",
            "fax_number": "757-473-5161"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLACKISTON",
        "first_name": "DIANE",
        "credential": "LCSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-09-27",
        "last_updated": "2015-07-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "VA",
            "license": "0904004231",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "256690",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004945395",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OPTIMA",
            "identifier": "O84769",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VA PREMIER",
            "identifier": "004945395",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Andrew Black III, DPT, OCS
• Latesha Black, LCSW
• Mackenzie Cestare Black, LRIC
• Taylor Breanne Black
• Mason Blacker, MD
• Alsena Jacquline Blackman, PTA
• Jerome Scott Blackman, M.D.
• Jennifer Blackmon, D.C.
• Moriah-Jonelle Blackmon
• Eboni Blackshire-Thornton

• All providers in Virginia Beach, VA
• Clinical Social Worker in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 29, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.