Provider Demographics
NPI:1194296350
Name:BILOTTA BLACKMAN, MARY ANN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:BILOTTA BLACKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-2504
Mailing Address - Country:US
Mailing Address - Phone:978-534-7735
Mailing Address - Fax:978-534-1765
Practice Address - Street 1:122 GRANITE ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-2504
Practice Address - Country:US
Practice Address - Phone:978-534-7735
Practice Address - Fax:978-534-1765
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10269941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical