MEDICARE: REGINA A BLACKWOLF MSW, LICSW

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	CP00005962	WA
2	1041C0700X	Clinical Social Worker	LW60083962	WA

General Provider Information

NPI Number	:	1184777252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINA A BLACKWOLF MSW, LICSW

Provider Business Mailing Address
First Line	:	12812 3RD AVE SE STE A
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98208-6455
Country	:	US
Telephone Number	:	206-375-7657
Fax Number	:	206-319-5325

Provider Business Practice Location Address
First Line	:	12812 3RD AVE SE STE A
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98208-6455
Country	:	US
Telephone Number	:	206-375-7657
Fax Number	:	206-319-5325

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

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	03/03/2023

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