MEDICARE: DR. LEE ROY BLACKWELL PH.D.

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
1	103TC1900X	Counseling Psychologist	PSY5642	CA

General Provider Information

NPI Number	:	1306995089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEE ROY BLACKWELL PH.D.

Provider Business Mailing Address
First Line	:	16152 BEACH BLVD STE 170
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-3818
Country	:	US
Telephone Number	:	714-848-7280
Fax Number	:	714-847-8909

Provider Business Practice Location Address
First Line	:	16152 BEACH BLVD STE 170
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-3818
Country	:	US
Telephone Number	:	714-848-7280
Fax Number	:	714-847-8909

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	07/08/2007

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