Provider Demographics
NPI:1639716525
Name:BLACKWELL, BRANDY LYNN (CADC 1)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:LYNN
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:CADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8549
Mailing Address - Street 2:
Mailing Address - City:COBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97408-1313
Mailing Address - Country:US
Mailing Address - Phone:541-284-5673
Mailing Address - Fax:
Practice Address - Street 1:91150 N COBURG INDUSTRIAL WAY
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408-1313
Practice Address - Country:US
Practice Address - Phone:541-284-5673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-P-15101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1104934892OtherNPI