Provider Demographics
NPI:1669423745
Name:GOLDBLATT, NANCY R (LCSWC)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:R
Last Name:GOLDBLATT
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 ROUNDHILL RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-2213
Mailing Address - Country:US
Mailing Address - Phone:410-235-0630
Mailing Address - Fax:
Practice Address - Street 1:1620 ROUNDHILL RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2213
Practice Address - Country:US
Practice Address - Phone:410-235-0630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD052351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD205401903Medicaid
MDQ928Medicare PIN