Provider Demographics
NPI:1689605230
Name:BLACKTOP, ANN MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:BLACKTOP
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-1190
Mailing Address - Country:US
Mailing Address - Phone:231-873-5675
Mailing Address - Fax:231-873-4805
Practice Address - Street 1:611 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1190
Practice Address - Country:US
Practice Address - Phone:231-873-5675
Practice Address - Fax:231-873-4805
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAB0335701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI800F410320OtherBCBSMI
MI383119096OtherTAX ID
MI8008974220OtherBCBS
MI383119096OtherTAX ID
MI800F410320OtherBCBSMI