Provider Demographics
NPI:1124832654
Name:BLACKWELL, SHANAE ARIEL (LMT)
Entity type:Individual
Prefix:
First Name:SHANAE
Middle Name:ARIEL
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7634 EAGLE PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250-5201
Mailing Address - Country:US
Mailing Address - Phone:210-803-9632
Mailing Address - Fax:
Practice Address - Street 1:7634 EAGLE PARK DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78250-5201
Practice Address - Country:US
Practice Address - Phone:210-803-9632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT143064225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist