Provider Demographics
NPI:1366735227
Name:BLICKENSTAFF, ERIC JOHN (LCSW)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JOHN
Last Name:BLICKENSTAFF
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4067 DAVIDSON ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-6325
Mailing Address - Country:US
Mailing Address - Phone:503-708-6190
Mailing Address - Fax:
Practice Address - Street 1:891 NW GRANT AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4539
Practice Address - Country:US
Practice Address - Phone:503-708-6190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL46691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical