Provider Demographics
NPI:1356042048
Name:BLACKMAN, COLLEEN ELIZABETH
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ELIZABETH
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8935 LAWLOR ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-4329
Mailing Address - Country:US
Mailing Address - Phone:510-502-1802
Mailing Address - Fax:
Practice Address - Street 1:8935 LAWLOR ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-4329
Practice Address - Country:US
Practice Address - Phone:510-502-1802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA145645106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist