Provider Demographics
NPI:1811088446
Name:BLACKWELL, DIANA (LCSW)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 N TRUMAN BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63019-1344
Mailing Address - Country:US
Mailing Address - Phone:636-931-8784
Mailing Address - Fax:636-465-0026
Practice Address - Street 1:508 N TRUMAN BLVD STE F
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:MO
Practice Address - Zip Code:63019-1344
Practice Address - Country:US
Practice Address - Phone:636-931-8784
Practice Address - Fax:636-465-0026
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0059111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493964837Medicaid