Provider Demographics
NPI:1871222570
Name:BLACKWELL, HERBERT ALLEN JR (MT)
Entity Type:Individual
Prefix:MR
First Name:HERBERT
Middle Name:ALLEN
Last Name:BLACKWELL
Suffix:JR
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:108 JEFFERYS DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-3022
Mailing Address - Country:US
Mailing Address - Phone:757-725-0617
Mailing Address - Fax:
Practice Address - Street 1:3630 GEORGE WASHINGTON HWY
Practice Address - Street 2:SUITE A
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-2360
Practice Address - Country:US
Practice Address - Phone:757-725-0617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019010331225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist