Provider Demographics
NPI:1891550315
Name:BLACKWOOD, OLIVE BEAR
Entity Type:Individual
Prefix:
First Name:OLIVE
Middle Name:BEAR
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 77964
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28271-7022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2032
Practice Address - Country:US
Practice Address - Phone:980-236-0734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X, 103TA0700X, 103TF0000X
NC106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily