Healthcare Provider Details

I. General information

NPI: 1619468204
Provider Name (Legal Business Name): RACHEL ILISA BLACKMER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2018
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 EDWARDS ST
HARTFORD CT
06120-2812
US

IV. Provider business mailing address

29 KENNEDY DR
ENFIELD CT
06082-5315
US

V. Phone/Fax

Practice location:
  • Phone: 860-695-6900
  • Fax:
Mailing address:
  • Phone: 860-550-3020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number000225947
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11538
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: