Provider Demographics
NPI:1194077222
Name:KATHERINE BLACKWELL, LCSW - LIFE SERVICES
Entity type:Organization
Organization Name:KATHERINE BLACKWELL, LCSW - LIFE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:352-409-4077
Mailing Address - Street 1:2117 STEWART LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-9507
Mailing Address - Country:US
Mailing Address - Phone:352-409-4077
Mailing Address - Fax:
Practice Address - Street 1:2117 STEWART LN
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-9507
Practice Address - Country:US
Practice Address - Phone:352-409-4077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW95811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty