Provider Demographics
NPI:1477785541
Name:ALLEN, KATHERINE LORA BLACKSTONE (LICSW, MHP, CMHS)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LORA BLACKSTONE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LICSW, MHP, CMHS
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:BLACKSTONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:PO BOX 2394
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8455
Mailing Address - Country:US
Mailing Address - Phone:360-200-5419
Mailing Address - Fax:360-200-6736
Practice Address - Street 1:910 16TH AVE STE 120
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2374
Practice Address - Country:US
Practice Address - Phone:360-200-5419
Practice Address - Fax:360-200-6736
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60424218104100000X, 1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2122309Medicaid