Basic Information
| Provider Information | |||||||||
| NPI: | 1356353486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLADES | ||||||||
| FirstName: | DOTTIE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9054 | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376159054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234673600 | ||||||||
| FaxNumber: | 4234673696 | ||||||||
| Practice Location | |||||||||
| Address1: | 1570 WAVERLY RD | ||||||||
| Address2: | HOLSTON COUNSELING SERV | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232241300 | ||||||||
| FaxNumber: | 4232241321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LSW4548 | TN | X | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | LSW4548 | TN | X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 184295 | 01 | ANTHEM PROF TRIGON HOLSTO | OTHER | 4111436 | 01 | MAGELLAN NAVIGATOR | OTHER | 368130 | 01 | MANAGED HEALTH NET | OTHER | 4111436 | 01 | MAGELLAN SUMMIT | OTHER | 334969 | 01 | VALUEOPTIONS GROUP | OTHER | 184295 | 01 | ANTHEMPREF TRIGON HOLSTON | OTHER | 4111436 | 01 | MAGELLAN PINNACLE | OTHER | 5665594 | 01 | FIRST HEALTH | OTHER | 3920247 | 01 | TN | MEDICAID CROSSO GRP | OTHER | 3987069 | 01 | TN | MEDICAID CROSSO | OTHER |