Provider Demographics
NPI:1609319052
Name:BLACKWELL, RAUVI VIDAD
Entity Type:Individual
Prefix:MS
First Name:RAUVI
Middle Name:VIDAD
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 1:1208 SUNDOWN DR
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-3998
Mailing Address - Country:US
Mailing Address - Phone:469-993-4920
Mailing Address - Fax:
Practice Address - Street 1:860 HEBRON PKWY
Practice Address - Street 2:SUITE 1101
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-5151
Practice Address - Country:US
Practice Address - Phone:469-444-2244
Practice Address - Fax:214-488-1200
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132753363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health