Provider Demographics
NPI:1114072410
Name:BLANK, HOWARD C (LICSW)
Entity Type:Individual
Prefix:MR
First Name:HOWARD
Middle Name:C
Last Name:BLANK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-4331
Mailing Address - Country:US
Mailing Address - Phone:978-343-4695
Mailing Address - Fax:
Practice Address - Street 1:255 MAIN ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-4331
Practice Address - Country:US
Practice Address - Phone:978-343-4695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10221171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1041CO700XMedicaid
MA1041CO700XOtherCLINICAL