Provider Demographics
NPI:1083919518
Name:BLACKWELL HOUSE INC.
Entity Type:Organization
Organization Name:BLACKWELL HOUSE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALIFIED PROFESSIONAL/ DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:LATONYA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:TINNIN
Authorized Official - Suffix:
Authorized Official - Credentials:QP
Authorized Official - Phone:336-350-5492
Mailing Address - Street 1:2805 N OHENRY BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-4631
Mailing Address - Country:US
Mailing Address - Phone:336-375-3121
Mailing Address - Fax:
Practice Address - Street 1:2805 N OHENRY BLVD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-4631
Practice Address - Country:US
Practice Address - Phone:336-375-3121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC041-997320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness