Provider Demographics
NPI:1578516860
Name:BUCHHOLZ-BLACKBURN, CAROL (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BUCHHOLZ-BLACKBURN
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 1:7325 STATE ROUTE 5
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-3435
Mailing Address - Country:US
Mailing Address - Phone:315-859-1973
Mailing Address - Fax:315-859-1979
Practice Address - Street 1:7325 STATE ROUTE 5
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-3435
Practice Address - Country:US
Practice Address - Phone:315-859-1973
Practice Address - Fax:315-859-1979
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0504091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01039156Medicaid
NY01039156Medicaid