Provider Demographics
NPI:1013387992
Name:BLACKWELL, JOSEPH (M S)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:M S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5234 PLAZA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-6515
Mailing Address - Country:US
Mailing Address - Phone:219-614-8446
Mailing Address - Fax:
Practice Address - Street 1:6049 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2619
Practice Address - Country:US
Practice Address - Phone:219-614-8446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN13618911Medicaid