Provider Demographics
NPI:1346971579
Name:BLACKWELL, AMANDA REBECCA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:REBECCA
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6837 40TH LN N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-6178
Mailing Address - Country:US
Mailing Address - Phone:727-741-5684
Mailing Address - Fax:
Practice Address - Street 1:29149 CHAPEL PARK DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-4423
Practice Address - Country:US
Practice Address - Phone:813-575-8199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW209221041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1144988080OtherNPI