Healthcare Provider Details

I. General information

NPI: 1851433668
Provider Name (Legal Business Name): DEALY E. BLACKSHEAR LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5TH AND DIVISION STREETS
NOME AK
99762
US

IV. Provider business mailing address

PO BOX 1802 605 LOMENS STREET
NOME AK
99762-1802
US

V. Phone/Fax

Practice location:
  • Phone: 907-443-3289
  • Fax: 907-443-5915
Mailing address:
  • Phone: 907-443-3289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number635
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: