Provider Demographics
NPI:1871011486
Name:BLACKWELL, JUSTIN LEE (CAP, ICADC, CAC-AD)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:LEE
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:CAP, ICADC, CAC-AD
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:LEE
Other - Last Name:ARRILDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAP, ICADC, CAC-AD
Mailing Address - Street 1:1415 HOMESTEAD RD N
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-4830
Mailing Address - Country:US
Mailing Address - Phone:239-491-8092
Mailing Address - Fax:239-491-9213
Practice Address - Street 1:1415 HOMESTEAD RD N
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-4830
Practice Address - Country:US
Practice Address - Phone:239-491-8092
Practice Address - Fax:239-491-9213
Is Sole Proprietor?:No
Enumeration Date:2017-09-04
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLICADC.0000031101YA0400X
MDAC2946101YA0400X
MDPR0153175T00000X
FLCAP.0100424101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist