Provider Demographics
NPI:1881833929
Name:BLACKWELL, CAROLINE ANISSA (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:ANISSA
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 CORPORATE CENTER DR STE 430
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-7668
Mailing Address - Country:US
Mailing Address - Phone:323-526-4016
Mailing Address - Fax:
Practice Address - Street 1:4701 E CESAR E CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1209
Practice Address - Country:US
Practice Address - Phone:323-881-3799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 21847104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker