Provider Demographics
NPI:1922635614
Name:BLACKSTONE, CHELSEA PETRINA (LMSW)
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:PETRINA
Last Name:BLACKSTONE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:CHELSEA
Other - Middle Name:PETRINA
Other - Last Name:BLACKSTONE-STROTHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:2624 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-4938
Mailing Address - Country:US
Mailing Address - Phone:208-676-6380
Mailing Address - Fax:
Practice Address - Street 1:2624 N 12TH ST
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-4938
Practice Address - Country:US
Practice Address - Phone:208-676-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-39252104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker