Provider Demographics
NPI:1194925461
Name:BLACKMAR, CHARLES (LCSW)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BLACKMAR
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6118 SE BELMONT ST STE 402
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1983
Mailing Address - Country:US
Mailing Address - Phone:503-220-6213
Mailing Address - Fax:
Practice Address - Street 1:6118 SE BELMONT ST STE 402
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1983
Practice Address - Country:US
Practice Address - Phone:712-206-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101YM0800X, 372600000X
ORL65041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No372600000XNursing Service Related ProvidersAdult Companion