Provider Demographics
NPI:1245650845
Name:IRENE T BLACKFORD PHD LLC
Entity type:Organization
Organization Name:IRENE T BLACKFORD PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:814-873-4141
Mailing Address - Street 1:1373B W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2503
Mailing Address - Country:US
Mailing Address - Phone:814-873-4141
Mailing Address - Fax:814-459-4673
Practice Address - Street 1:1373B W 6TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-2503
Practice Address - Country:US
Practice Address - Phone:814-873-4141
Practice Address - Fax:814-459-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006739103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA349983OtherMEDICARE PTAN