Provider Demographics
NPI:1053714907
Name:BLACKWELL, LAVELLE JR
Entity type:Individual
Prefix:MR
First Name:LAVELLE
Middle Name:
Last Name:BLACKWELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7830 CONTEE RD
Mailing Address - Street 2:#129
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-9231
Mailing Address - Country:US
Mailing Address - Phone:216-789-0509
Mailing Address - Fax:
Practice Address - Street 1:4601 MARTIN LUTHER KING JR AVE SW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-1131
Practice Address - Country:US
Practice Address - Phone:202-261-6598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOT010000978225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist