Provider Demographics
NPI:1336202886
Name:BLACKWELL, SOPHIA R
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:R
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 1:2479 COUNTRY CLUB RD
Mailing Address - Street 2:1600D
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-4201
Mailing Address - Country:US
Mailing Address - Phone:846-263-7794
Mailing Address - Fax:864-582-9208
Practice Address - Street 1:2479 COUNTRY CLUB RD
Practice Address - Street 2:1600D
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-4201
Practice Address - Country:US
Practice Address - Phone:846-263-7794
Practice Address - Fax:864-582-9208
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator