=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013513894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CINDY BLACKLIDGE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2020
-----------------------------------------------------
Last Update Date | 01/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1177 PERSHING AVE
-----------------------------------------------------
City | FORT EUSTIS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23604-1406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-587-6001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5116 N HIGHWAY 61
-----------------------------------------------------
City | SAINT MARY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63673-7102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-587-6001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904017812
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C10541
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2017043723
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------