Provider Demographics
NPI:1508303116
Name:BUSH BLACKWELL, LYNETTE
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:BUSH 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 1:11 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:WHEATLEY HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11798-1829
Mailing Address - Country:US
Mailing Address - Phone:631-920-6542
Mailing Address - Fax:
Practice Address - Street 1:11 WILLOW ST
Practice Address - Street 2:
Practice Address - City:WHEATLEY HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11798-1829
Practice Address - Country:US
Practice Address - Phone:631-920-6542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-21
Last Update Date:2017-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician