Provider Demographics
NPI:1598137127
Name:BLACKWELL, MELISSA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5565 STERRETT PL
Mailing Address - Street 2:STE 320
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2665
Mailing Address - Country:US
Mailing Address - Phone:410-772-7155
Mailing Address - Fax:
Practice Address - Street 1:5565 STERRETT PL
Practice Address - Street 2:STE 320
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2665
Practice Address - Country:US
Practice Address - Phone:410-772-7155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05153103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist