Provider Demographics
NPI:1598107179
Name:BLACKWELL, CYNTHIA (MSW, M ED)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MSW, M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E GORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-3025
Mailing Address - Country:US
Mailing Address - Phone:580-215-0255
Mailing Address - Fax:
Practice Address - Street 1:702 NW HOMESTEAD DR
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5205
Practice Address - Country:US
Practice Address - Phone:580-215-0255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12212101YA0400X
OK5323101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health