1043769839 NPI number — MS. ERIN ELIZABETH BLACKWELL LCSW

Table of content: (NPI 1053614271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043769839 NPI number — MS. ERIN ELIZABETH BLACKWELL LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKWELL
Provider First Name:
ERIN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FUELLING
Provider Other First Name:
ERIN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043769839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARRENSBURG
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64093-0768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-429-6678
Provider Business Mailing Address Fax Number:
660-429-6672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 E RUSSELL AVE STE A4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARRENSBURG
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64093-1242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-429-6678
Provider Business Practice Location Address Fax Number:
660-429-6672
Provider Enumeration Date:
09/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  2014040085 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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