Provider Demographics
NPI:1174194096
Name:BLACKWELDER, BRITTANY (HIS)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:BLACKWELDER
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16354 COUNTY ROAD 30
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1207
Mailing Address - Country:US
Mailing Address - Phone:763-315-6571
Mailing Address - Fax:763-315-6687
Practice Address - Street 1:16354 COUNTY ROAD 30
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-1207
Practice Address - Country:US
Practice Address - Phone:763-315-6571
Practice Address - Fax:763-315-6687
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2887237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist