Provider Demographics
NPI:1396387320
Name:BLACKWELL, SEAN
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 W REYNOLDS AVE SW
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531
Mailing Address - Country:US
Mailing Address - Phone:360-330-9044
Mailing Address - Fax:
Practice Address - Street 1:2428 W REYNOLDS AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4554
Practice Address - Country:US
Practice Address - Phone:360-330-9044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical