Provider Demographics
NPI:1669472247
Name:BLACKBURN, CAROLYN W (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:W
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:WOOD
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:329 BATH RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2673
Mailing Address - Country:US
Mailing Address - Phone:207-373-3070
Mailing Address - Fax:207-373-3070
Practice Address - Street 1:329 BATH RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2673
Practice Address - Country:US
Practice Address - Phone:207-373-3070
Practice Address - Fax:207-373-3070
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC73161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME287340099Medicaid
ME287340099Medicaid