Provider Demographics
NPI:1598356701
Name:BLACKNELL, LORETTA
Entity Type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:
Last Name:BLACKNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108-3017
Mailing Address - Country:US
Mailing Address - Phone:973-202-3046
Mailing Address - Fax:
Practice Address - Street 1:129 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07108-3017
Practice Address - Country:US
Practice Address - Phone:862-763-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-30
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SLO59619001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical