Healthcare Provider Details

I. General information

NPI: 1407776099
Provider Name (Legal Business Name): MARIE JOELLE BLACKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 HAZEN ST
EAST ELMHURST NY
11370-1210
US

IV. Provider business mailing address

449 STANLEY PL
RAHWAY NJ
07065-2519
US

V. Phone/Fax

Practice location:
  • Phone: 718-809-2388
  • Fax:
Mailing address:
  • Phone: 718-809-2388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number016664
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: