Provider Demographics
NPI:1831904218
Name:BLACKWELL, ANGELIQUE NICOLE (CGG61649106)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:NICOLE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:CGG61649106
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S GRADY WAY STE 245
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-3209
Mailing Address - Country:US
Mailing Address - Phone:206-679-8291
Mailing Address - Fax:206-274-6252
Practice Address - Street 1:15 S GRADY WAY STE 245
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-3209
Practice Address - Country:US
Practice Address - Phone:206-679-8291
Practice Address - Fax:206-274-6252
Is Sole Proprietor?:No
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61649160101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor