Provider Demographics
NPI:1457072654
Name:BLACKWELL, CHRISTIAN A
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:A
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 S ORANGE AVE # 1164
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:274 BOYDEN AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3010
Practice Address - Country:US
Practice Address - Phone:201-407-3977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL066597001041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool