Provider Demographics
NPI:1386846715
Name:BLACKMORE, WILLIS EDWIN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:WILLIS
Middle Name:EDWIN
Last Name:BLACKMORE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4787 NDCBU
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6032
Mailing Address - Country:US
Mailing Address - Phone:505-737-0142
Mailing Address - Fax:
Practice Address - Street 1:1337 GUSDORF ROAD, SUITES E & F
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6489
Practice Address - Country:US
Practice Address - Phone:575-758-4297
Practice Address - Fax:575-751-7237
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-048311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical