Provider Demographics
NPI:1811407133
Name:BLACKWOOD, DIANE MARIE (LMSW LADC)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MARIE
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:LMSW LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 UNION ST
Mailing Address - Street 2:
Mailing Address - City:VERNON ROCKVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06066-3126
Mailing Address - Country:US
Mailing Address - Phone:860-380-7228
Mailing Address - Fax:
Practice Address - Street 1:31 UNION ST
Practice Address - Street 2:
Practice Address - City:VERNON ROCKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06066-3126
Practice Address - Country:US
Practice Address - Phone:860-872-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1040104100000X
CT1239101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty