Provider Demographics
NPI:1306995089
Name:BLACKWELL, LEE ROY (PHD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:ROY
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16152 BEACH BLVD STE 170
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3818
Mailing Address - Country:US
Mailing Address - Phone:714-848-7280
Mailing Address - Fax:714-847-8909
Practice Address - Street 1:16152 BEACH BLVD STE 170
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3818
Practice Address - Country:US
Practice Address - Phone:714-848-7280
Practice Address - Fax:714-847-8909
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5642103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling