Provider Demographics
NPI:1649056060
Name:BLACKWELL, SCHERESE M
Entity type:Individual
Prefix:
First Name:SCHERESE
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 1:7900 LINDBERGH BLVD APT 3605
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19153-2009
Mailing Address - Country:US
Mailing Address - Phone:213-806-0121
Mailing Address - Fax:
Practice Address - Street 1:1822 SPRING GARDEN ST SIDE 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-4138
Practice Address - Country:US
Practice Address - Phone:215-607-6835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician