=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912500505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANA BLACKWOOD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2020
-----------------------------------------------------
Last Update Date | 11/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 W 36TH ST FL SUITE5N
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10018-7907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-740-7199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 CEDAR ST
-----------------------------------------------------
City | VALLEY STREAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11580-4908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-780-3804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------