Provider Demographics
NPI:1801297734
Name:BLACKWOOD, CALLIE RANAE (LAC)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:RANAE
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 W MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-3810
Mailing Address - Country:US
Mailing Address - Phone:406-570-8792
Mailing Address - Fax:
Practice Address - Street 1:2417 W MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-3810
Practice Address - Country:US
Practice Address - Phone:406-570-8792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-ACU-LIC-30564171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist