Provider Demographics
NPI:1003572611
Name:BLACKWELL, REBEKAH LYNN
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:LYNN
Last Name:BLACKWELL
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 1:124 E MIRACLE STRIP PKWY STE 503
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1991
Mailing Address - Country:US
Mailing Address - Phone:850-301-0438
Mailing Address - Fax:
Practice Address - Street 1:124 E MIRACLE STRIP PKWY STE 503
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1991
Practice Address - Country:US
Practice Address - Phone:844-729-2242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-19165103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst