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General NPI Number Information
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NPI Number | 1699319152
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Entity Type | Organization
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Legal Business Name | THOMAS BLACKWELL, LCSW, LLC
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Dates
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Enumeration Date | 10/28/2019
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Last Update Date | 07/22/2020
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Provider Practice Location Address
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Address Line | 2945 MAIN ST STE A
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City | STRATFORD
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State | CT
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Zip | 06614-4978
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Country | US
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Telephone | 203-814-2176
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Fax |
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Provider Business Mailing Address
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Address Line | 80 VIRGINIA AVE
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City | BRIDGEPORT
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State | CT
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Zip | 06610-1506
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Country | US
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Telephone | 203-814-2176
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Fax | 203-330-1237
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Authorized Official
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Title or Position | OWNER
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Name | THOMAS BLACKWELL
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Credential | LCSW
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Telephone | 203-814-2176
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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 |
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License Number State |
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