Provider Demographics
NPI:1457244139
Name:WILSON LOVE BLACKWELL, ANDREA ANTOINETTE
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:ANTOINETTE
Last Name:WILSON LOVE 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 1:6644 PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-3128
Mailing Address - Country:US
Mailing Address - Phone:513-972-9480
Mailing Address - Fax:
Practice Address - Street 1:500 MADISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1230
Practice Address - Country:US
Practice Address - Phone:567-312-8700
Practice Address - Fax:567-312-8793
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-31
Last Update Date:2025-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator