Provider Demographics
NPI:1710599543
Name:BLACKWELL, RAYMOND (LADAC II)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:LADAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 ROYAL ELM CIR
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37074-2004
Mailing Address - Country:US
Mailing Address - Phone:615-330-0161
Mailing Address - Fax:
Practice Address - Street 1:832 MAIN ST SOUTH
Practice Address - Street 2:
Practice Address - City:BRUSH CREEK
Practice Address - State:TN
Practice Address - Zip Code:38547
Practice Address - Country:US
Practice Address - Phone:615-630-8908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDC0000001425101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty