MEDICARE: GRACE M BLACKWOOD LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC004495	GA

General Provider Information

NPI Number	:	1104071133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE M BLACKWOOD LPC

Provider Business Mailing Address
First Line	:	570 WINDSOR WAY
Second Line	:
City	:	FAIRBURN
State	:	GA
Zip	:	30213-6446
Country	:	US
Telephone Number	:	770-365-3140
Fax Number	:	770-703-7915

Provider Business Practice Location Address
First Line	:	570 WINDSOR WAY
Second Line	:
City	:	FAIRBURN
State	:	GA
Zip	:	30213-6446
Country	:	US
Telephone Number	:	770-365-3140
Fax Number	:	770-703-7915

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2008
Last Update Date	:	01/26/2016

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Directions to “ GRACE M BLACKWOOD LPC” Practice Location

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