Provider Demographics
NPI:1316246838
Name:BLACKWELL, TINA M (PC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 KINGVIEW DRIVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-8336
Mailing Address - Country:US
Mailing Address - Phone:513-228-7854
Mailing Address - Fax:513-228-7848
Practice Address - Street 1:204 COOK RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-9600
Practice Address - Country:US
Practice Address - Phone:513-695-1357
Practice Address - Fax:513-695-2952
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC-500248101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health