Provider Demographics
NPI:1720147119
Name:BLACKWELL, KELLEY M (LMFT)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:M
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185-3392
Mailing Address - Country:US
Mailing Address - Phone:931-296-9813
Mailing Address - Fax:931-296-9853
Practice Address - Street 1:795 HOLLY LN
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185
Practice Address - Country:US
Practice Address - Phone:931-296-9813
Practice Address - Fax:931-296-9853
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN567106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1509225Medicaid