Provider Demographics
NPI:1346584620
Name:BLACKWELL, DANIELLE (MS, LAT/ATC)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MS, LAT/ATC
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:CANONGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LAT/ATC
Mailing Address - Street 1:723 SAINT MARYS ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-1424
Mailing Address - Country:US
Mailing Address - Phone:919-856-7810
Mailing Address - Fax:
Practice Address - Street 1:723 SAINT MARYS ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1424
Practice Address - Country:US
Practice Address - Phone:919-856-7810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1722174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist