Healthcare Provider Details

I. General information

NPI: 1942642087
Provider Name (Legal Business Name): REBECCA BLACKWOOD LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 GOUGLER AVE
KENT OH
44240-2401
US

IV. Provider business mailing address

1034 MIDDLEBURY RD
KENT OH
44240-3380
US

V. Phone/Fax

Practice location:
  • Phone: 330-677-4724
  • Fax:
Mailing address:
  • Phone: 412-965-8648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.1700731
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW017741
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1700731
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: