Provider Demographics
NPI:1972018497
Name:BLACKFORD, COLLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:BLACKFORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:CREAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:165 N VILLAGE AVE STE 216
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3701
Mailing Address - Country:US
Mailing Address - Phone:516-665-9669
Mailing Address - Fax:516-665-9670
Practice Address - Street 1:165 N VILLAGE AVE STE 216
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3701
Practice Address - Country:US
Practice Address - Phone:516-665-9669
Practice Address - Fax:516-665-9670
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085532-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical