Provider Demographics
NPI:1528934973
Name:BLACKWELL, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
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 PECAN GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-3940
Mailing Address - Country:US
Mailing Address - Phone:251-272-6334
Mailing Address - Fax:
Practice Address - Street 1:1691 BIENVILLE DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3756
Practice Address - Country:US
Practice Address - Phone:318-343-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1978226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapistGroup - Multi-Specialty