Provider Demographics
NPI:1629505326
Name:BLACKWELL, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
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 1:1 WINDSOR CV
Mailing Address - Street 2:SUITE 303
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-1833
Mailing Address - Country:US
Mailing Address - Phone:803-865-8601
Mailing Address - Fax:803-626-1120
Practice Address - Street 1:1 WINDSOR CV
Practice Address - Street 2:SUITE 303
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1833
Practice Address - Country:US
Practice Address - Phone:803-865-8601
Practice Address - Fax:803-626-1120
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC98111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical