Provider Demographics
NPI:1699319152
Name:THOMAS BLACKWELL, LCSW, LLC
Entity type:Organization
Organization Name:THOMAS BLACKWELL, LCSW, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-814-2176
Mailing Address - Street 1:80 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-1506
Mailing Address - Country:US
Mailing Address - Phone:203-814-2176
Mailing Address - Fax:203-330-1237
Practice Address - Street 1:2945 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-4978
Practice Address - Country:US
Practice Address - Phone:203-814-2176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-28
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty