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General NPI Number Information
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NPI Number | 1285861716
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Entity Type | Individual
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Provider Name | E. LAWRENCE BLACKWELL JR. LCSW, CAC
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Gender | Male
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Dates
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Enumeration Date | 06/10/2009
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Last Update Date | 06/10/2009
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Provider Practice Location Address
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Address Line | 140 GLASTONBURY BLVD SOMERSET SQ. 2ND FLOOR
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City | GLASTONBURY
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State | CT
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Zip | 06033-4402
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Country | US
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Telephone | 860-212-5824
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Fax |
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Provider Business Mailing Address
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Address Line | 81 REDWOOD RD
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City | MANCHESTER
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State | CT
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Zip | 06040-6329
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Country | US
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Telephone | 860-643-4684
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 004581
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License Number State | CT
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