Provider Demographics
NPI:1376231795
Name:BLACKWELL, TYERA (BCBA)
Entity type:Individual
Prefix:
First Name:TYERA
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ENTERPRISE PL STE 1
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-8202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 ENTERPRISE PL STE 1
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-8207
Practice Address - Country:US
Practice Address - Phone:302-678-3353
Practice Address - Fax:302-678-9245
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
DE1-25-78811103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health