Provider Demographics
NPI:1366536641
Name:BLACKWELL, DELORES (LCSW)
Entity type:Individual
Prefix:
First Name:DELORES
Middle Name:
Last Name:BLACKWELL
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 1:2265 5TH AVE
Mailing Address - Street 2:APT MH
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-2019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2265 5TH AVENUE
Practice Address - Street 2:APT MH
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037
Practice Address - Country:US
Practice Address - Phone:917-445-2023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0698261041C0700X
MD133991041C0700X
NCC0066511041C0700X
GACSW90043131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical