Provider Demographics
NPI:1225435373
Name:BLACKWELL, LISA C
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:C
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2629
Mailing Address - Country:US
Mailing Address - Phone:718-816-3481
Mailing Address - Fax:
Practice Address - Street 1:400 LAKE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-2629
Practice Address - Country:US
Practice Address - Phone:718-816-3481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No252Y00000XAgenciesEarly Intervention Provider Agency