Provider Demographics
NPI:1326330424
Name:BLACKWELL, THOMAS JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:BLACKWELL
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Practice Address - Street 1:80 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-1506
Practice Address - Country:US
Practice Address - Phone:203-814-2176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-07
Last Update Date:2011-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0075991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical