Provider Demographics
NPI:1780849067
Name:BLACKWELDER, DAVID E (PH D)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:E
Last Name:BLACKWELDER
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 STONEBROOK CT
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2266
Mailing Address - Country:US
Mailing Address - Phone:262-783-6708
Mailing Address - Fax:
Practice Address - Street 1:2020 W WELLS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2720
Practice Address - Country:US
Practice Address - Phone:414-937-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1963103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical