Provider Demographics
NPI:1659019248
Name:BLACKWELL, ALARIC REMINGTON LANE (CSA)
Entity Type:Individual
Prefix:
First Name:ALARIC
Middle Name:REMINGTON LANE
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:CSA
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 64
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41022-0064
Mailing Address - Country:US
Mailing Address - Phone:859-957-9975
Mailing Address - Fax:
Practice Address - Street 1:541 BUTTERMILK PIKE STE 200
Practice Address - Street 2:
Practice Address - City:CRESCENT SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:41017-1696
Practice Address - Country:US
Practice Address - Phone:859-859-2023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1204754171M00000X
KY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty