Healthcare Provider Details

I. General information

NPI: 1558334938
Provider Name (Legal Business Name): SUSAN BLAKSTONE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 DOUCET RD
LAFAYETTE LA
70503-3407
US

IV. Provider business mailing address

PO BOX 1254
BROUSSARD LA
70518-1254
US

V. Phone/Fax

Practice location:
  • Phone: 337-989-2084
  • Fax:
Mailing address:
  • Phone: 337-837-9837
  • Fax: 337-837-3616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2215
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: