Provider Demographics
NPI:1619273406
Name:BLACKFORD, IRENE T (PHD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:T
Last Name:BLACKFORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:T
Other - Last Name:BLACKFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1373B W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2503
Mailing Address - Country:US
Mailing Address - Phone:814-873-4141
Mailing Address - Fax:814-459-4673
Practice Address - Street 1:1373B W 6TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-2503
Practice Address - Country:US
Practice Address - Phone:814-873-4141
Practice Address - Fax:814-459-4673
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006739L103T00000X, 103TC0700X
PAPS006739103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA226411OtherMEDICARE PTAN