Provider Demographics
NPI:1497812309
Name:BLACKMAN, WAYNE
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25333 147TH DR
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2823
Mailing Address - Country:US
Mailing Address - Phone:347-757-0365
Mailing Address - Fax:
Practice Address - Street 1:108-19 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420
Practice Address - Country:US
Practice Address - Phone:718-845-2620
Practice Address - Fax:718-845-9380
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00073111104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00073111Medicare ID - Type Unspecified