MEDICARE: STACY LYN BLACKWELL LMSW

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	1041C0700X	Clinical Social Worker	6801095510	MI

General Provider Information

NPI Number	:	1174962617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY LYN BLACKWELL LMSW

Provider Business Mailing Address
First Line	:	3122 CLYDE PARK AVE SW
Second Line	:
City	:	WYOMING
State	:	MI
Zip	:	49509-2918
Country	:	US
Telephone Number	:	989-802-9583
Fax Number	:

Provider Business Practice Location Address
First Line	:	678 FRONT AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-5325
Country	:	US
Telephone Number	:	616-916-3711
Fax Number	:	616-825-6015

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

Provider Enumeration Date	:	06/18/2013
Last Update Date	:	05/21/2025

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