Provider Demographics
NPI:1457004590
Name:BLACKWELL, KIZZY M
Entity type:Individual
Prefix:
First Name:KIZZY
Middle Name:M
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 PATRIOT DR STE A-5
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-8803
Mailing Address - Country:US
Mailing Address - Phone:888-433-3201
Mailing Address - Fax:
Practice Address - Street 1:108 PATRIOT DR STE A-5
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-8803
Practice Address - Country:US
Practice Address - Phone:302-803-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-29
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-23-70415103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst