Provider Demographics
NPI:1265824502
Name:BLACKWELL, SHANTAE
Entity Type:Individual
Prefix:
First Name:SHANTAE
Middle Name:
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 1:770 WOODLANE RD
Mailing Address - Street 2:
Mailing Address - City:WESTAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-3804
Mailing Address - Country:US
Mailing Address - Phone:609-267-5928
Mailing Address - Fax:
Practice Address - Street 1:1422 KEARSLEY RD
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-5205
Practice Address - Country:US
Practice Address - Phone:856-308-5891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health