Healthcare Provider Details

I. General information

NPI: 1962949941
Provider Name (Legal Business Name): ROBIN BLACKWELL ,LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 HARDWARE DR NE
ALBUQUERQUE NM
87109-2013
US

IV. Provider business mailing address

4810 HARDWARE DR NE
ALBUQUERQUE NM
87109-2013
US

V. Phone/Fax

Practice location:
  • Phone: 505-440-9303
  • Fax: 505-255-4717
Mailing address:
  • Phone: 505-440-9303
  • Fax: 505-255-4717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-05040
License Number StateNM

VIII. Authorized Official

Name: MS. ROBIN BLACKWELL
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 505-440-9303