Basic Information
Provider Information | |||||||||
NPI: | 1912505413 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BLACKSTOCK LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3204 ALTALOMA DR | ||||||||
Address2: |   | ||||||||
City: | VESTAVIA HILLS | ||||||||
State: | AL | ||||||||
PostalCode: | 352164265 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059999240 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2025 SHADY CREST DR STE 203 | ||||||||
Address2: |   | ||||||||
City: | HOOVER | ||||||||
State: | AL | ||||||||
PostalCode: | 352165417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059999240 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/15/2020 | ||||||||
LastUpdateDate: | 10/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLACKSTOCK | ||||||||
AuthorizedOfficialFirstName: | JOEL | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER / PSYCHOTHERAPIST | ||||||||
AuthorizedOfficialTelephone: | 2059999240 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | LICSW MSW PIP | ||||||||
NPICertificationDate: | 10/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.