MEDICARE: HEIDI ANNETTE BLACKSTUN MSW, LCSW, MBA

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	2001024582	MO

General Provider Information

NPI Number	:	1821028895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI ANNETTE BLACKSTUN MSW, LCSW, MBA

Provider Business Mailing Address
First Line	:	1810 CALEDON CT
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-8458
Country	:	US
Telephone Number	:	573-289-8144
Fax Number	:

Provider Business Practice Location Address
First Line	:	2012 CHERRY HILL DR STE 101
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-5882
Country	:	US
Telephone Number	:	573-289-8144
Fax Number	:

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

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	01/17/2023

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