Provider Demographics
NPI:1386973014
Name:BLACKWELL, TERENCE G JR
Entity type:Individual
Prefix:MR
First Name:TERENCE
Middle Name:G
Last Name:BLACKWELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:TERENCE
Other - Middle Name:G
Other - Last Name:BLACKWELL
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:BCBA
Mailing Address - Street 1:28 ADDINGTON CT
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-5302
Mailing Address - Country:US
Mailing Address - Phone:732-672-3471
Mailing Address - Fax:
Practice Address - Street 1:277 MAIN ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SOUTH RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08882-2042
Practice Address - Country:US
Practice Address - Phone:732-254-0300
Practice Address - Fax:732-254-3131
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-03-1234103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst