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NPI Code Detail

MEDICARE: MRS. CANDACE ALEXIS BLACKWOOD MS

MEDICARE: MRS. CANDACE ALEXIS BLACKWOOD MS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1033395512
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. CANDACE ALEXIS BLACKWOOD MS
Provider Business Mailing Address
First Line : 1825 MARIKA RD
Second Line :
City : FAIRBANKS
State : AK
Zip : 99709-5521
Country : US
Telephone Number : 907-474-0890
Fax Number : 907-451-8945
Provider Business Practice Location Address
First Line : 1825 MARIKA RD
Second Line :
City : FAIRBANKS
State : AK
Zip : 99709-5521
Country : US
Telephone Number : 907-474-0890
Fax Number : 907-451-8945
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/15/2008
Last Update Date : 01/15/2008

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