Provider Demographics
NPI:1346393667
Name:BLACKSTONE, DAVID BRADLEY (MSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:BRADLEY
Last Name:BLACKSTONE
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7111 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5303
Mailing Address - Country:US
Mailing Address - Phone:602-944-4630
Mailing Address - Fax:602-870-3890
Practice Address - Street 1:7111 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5303
Practice Address - Country:US
Practice Address - Phone:602-944-4630
Practice Address - Fax:602-870-3890
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-101181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP24786Medicare UPIN
AZ64418Medicare ID - Type Unspecified