Provider Demographics
NPI:1629093794
Name:BLACKMER, THERESA A
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:BLACKMER
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 1:883 PADDOCK AVE
Mailing Address - Street 2:RUSHFORD CENTER INC
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451-0000
Mailing Address - Country:US
Mailing Address - Phone:203-630-5216
Mailing Address - Fax:
Practice Address - Street 1:883 PADDOCK AVE
Practice Address - Street 2:RUSHFORD CENTER INC
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-0000
Practice Address - Country:US
Practice Address - Phone:203-630-5216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0012021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty