Provider Demographics
NPI:1184777252
Name:BLACKWOLF, REGINA A (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:A
Last Name:BLACKWOLF
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12812 3RD AVE SE STE A
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-6455
Mailing Address - Country:US
Mailing Address - Phone:206-375-7657
Mailing Address - Fax:206-319-5325
Practice Address - Street 1:12812 3RD AVE SE STE A
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6455
Practice Address - Country:US
Practice Address - Phone:206-375-7657
Practice Address - Fax:206-319-5325
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00005962101YA0400X
WALW600839621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)