Provider Demographics
NPI:1811279482
Name:BLACKWELL, OPHELIA MARLENE (PHD, LCPC, LPC, NCC)
Entity type:Individual
Prefix:DR
First Name:OPHELIA
Middle Name:MARLENE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PHD, LCPC, LPC, NCC
Other - Prefix:
Other - First Name:OPHELIA
Other - Middle Name:MARLENE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 NELLIE B AVE OFC 1
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-3339
Mailing Address - Country:US
Mailing Address - Phone:704-315-0897
Mailing Address - Fax:
Practice Address - Street 1:625 NELLIE B AVE OFC 1
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-3339
Practice Address - Country:US
Practice Address - Phone:888-447-8231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLCPC2305101YP2500X
GALPC011218101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional