Provider Demographics
NPI:1265141907
Name:BLACKSMITH, RENE JEAN (PRS)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:JEAN
Last Name:BLACKSMITH
Suffix:
Gender:F
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 HENNINGER RD APT 204
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-3366
Mailing Address - Country:US
Mailing Address - Phone:216-512-5469
Mailing Address - Fax:
Practice Address - Street 1:3305 HENNINGER RD APT 204
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-3366
Practice Address - Country:US
Practice Address - Phone:216-512-5469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.003691175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist