Healthcare Provider Details

I. General information

NPI: 1144926684
Provider Name (Legal Business Name): BLACKBIRD INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 34TH ST
OAKLAND CA
94609-2816
US

IV. Provider business mailing address

444 34TH ST
OAKLAND CA
94609-2816
US

V. Phone/Fax

Practice location:
  • Phone: 510-604-0428
  • Fax:
Mailing address:
  • Phone: 510-604-0428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. EUGENE P PORTER
Title or Position: OFFICER
Credential: MFT
Phone: 510-604-0428