Provider Demographics
NPI:1134731045
Name:BLACKWEST, LLC
Entity type:Organization
Organization Name:BLACKWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:HAILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:678-965-0653
Mailing Address - Street 1:703 ATLANTA RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2705
Mailing Address - Country:US
Mailing Address - Phone:770-886-6204
Mailing Address - Fax:
Practice Address - Street 1:703 ATLANTA RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2705
Practice Address - Country:US
Practice Address - Phone:770-886-6204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty