Provider Demographics
NPI:1114999372
Name:DAVIS, JOAN BLACKWOOD (HSPP)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:BLACKWOOD
Last Name:DAVIS
Suffix:
Gender:F
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-337-2438
Practice Address - Street 1:3008 BEVCHER DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-3863
Practice Address - Country:US
Practice Address - Phone:812-265-1918
Practice Address - Fax:812-265-1828
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041196A103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200172180AMedicaid
IN000000209017OtherANTHEM PIN
IN000000209017OtherANTHEM PIN
IN541910D7Medicare PIN