Provider Demographics
NPI:1134831951
Name:BLACKWELL, ELISSA
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:
Other - Last Name:BLACKWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2330 GOOD HOPE RD SE APT 719
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-4141
Mailing Address - Country:US
Mailing Address - Phone:347-373-3583
Mailing Address - Fax:
Practice Address - Street 1:1418 GOOD HOPE RD SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-5615
Practice Address - Country:US
Practice Address - Phone:202-796-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-23
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG50083168104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker