Provider Demographics
NPI:1053544056
Name:BLACKWELL, TANYA
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 E PARK AVE # 305
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-3860
Mailing Address - Country:US
Mailing Address - Phone:619-588-3653
Mailing Address - Fax:
Practice Address - Street 1:550 E PARK AVE # 305
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3860
Practice Address - Country:US
Practice Address - Phone:619-588-3653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health