Provider Demographics
NPI:1023855574
Name:BLANTON, BRENAI (LCSW)
Entity type:Individual
Prefix:
First Name:BRENAI
Middle Name:
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 1:10842 BRAVURA LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-3538
Mailing Address - Country:US
Mailing Address - Phone:682-900-1742
Mailing Address - Fax:
Practice Address - Street 1:2379 GUS THOMASSON RD STE 300
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-7102
Practice Address - Country:US
Practice Address - Phone:682-900-1742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical