Provider Demographics
NPI:1457492415
Name:BLACKMAN, SUSAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 MAPLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066-1011
Mailing Address - Country:US
Mailing Address - Phone:610-896-8180
Mailing Address - Fax:610-896-7113
Practice Address - Street 1:395 MAPLEWOOD RD
Practice Address - Street 2:
Practice Address - City:MERION STATION
Practice Address - State:PA
Practice Address - Zip Code:19066-1011
Practice Address - Country:US
Practice Address - Phone:610-896-8180
Practice Address - Fax:610-896-7113
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW002456-L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000008810025Medicaid
PA1000008810009Medicaid
645106KAIMedicare ID - Type Unspecified