Provider Demographics
NPI:1538639570
Name:BLACKWELL, WENDY ANN
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:ANN
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 1:4191 6TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-1249
Mailing Address - Country:US
Mailing Address - Phone:912-401-5020
Mailing Address - Fax:
Practice Address - Street 1:526 GAFFNEY RD STE 100
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4914
Practice Address - Country:US
Practice Address - Phone:907-687-5332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK190873103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst