Provider Demographics
NPI:1215511332
Name:BLACKBIRD COUNSELING
Entity type:Organization
Organization Name:BLACKBIRD COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:339-235-5116
Mailing Address - Street 1:28 RIVERSIDE DR STE 270
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:MA
Mailing Address - Zip Code:02359-4947
Mailing Address - Country:US
Mailing Address - Phone:774-773-6300
Mailing Address - Fax:
Practice Address - Street 1:28 RIVERSIDE DR STE 270
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:MA
Practice Address - Zip Code:02359-4947
Practice Address - Country:US
Practice Address - Phone:774-773-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACKBIRD COUNSELING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-06
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherN/A