MEDICARE: DR. RICHARD THOMAS BLACKWELL PHD

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	1628	NC

General Provider Information

NPI Number	:	1366707788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD THOMAS BLACKWELL PHD

Provider Business Mailing Address
First Line	:	2813 COLTSGATE RD
Second Line	:	SUITE 201
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3798
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2813 COLTSGATE RD
Second Line	:	SUITE 201
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3798
Country	:	US
Telephone Number	:	704-491-9646
Fax Number	:

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

Provider Enumeration Date	:	07/11/2012
Last Update Date	:	07/11/2012

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