Provider Demographics
NPI:1689921504
Name:BLACKWELL, REBECCA (BCBA)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 HOLLY DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-4639
Mailing Address - Country:US
Mailing Address - Phone:314-749-7768
Mailing Address - Fax:888-507-4453
Practice Address - Street 1:1333 WEST LOCKWOOD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-4817
Practice Address - Country:US
Practice Address - Phone:800-780-6545
Practice Address - Fax:888-507-4453
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011007859103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst