1790154490 NPI number — MR. JOEL THOMAS BLACKSTOCK JR. MSW, LGSW

Table of content: MR. JOEL THOMAS BLACKSTOCK JR. MSW, LGSW (NPI 1790154490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790154490 NPI number — MR. JOEL THOMAS BLACKSTOCK JR. MSW, LGSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKSTOCK
Provider First Name:
JOEL
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MSW, LGSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790154490
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 RALEIGH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-999-9240
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1720 2ND AVE. SOUTH
Provider Second Line Business Practice Location Address:
CCB 4TH FLOOR
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35294-2050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-934-4108
Provider Business Practice Location Address Fax Number:
205-975-8950
Provider Enumeration Date:
09/23/2015

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: 104100000X , with the licence number:  3768G , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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