Healthcare Provider Details

I. General information

NPI: 1306595384
Provider Name (Legal Business Name): DR. HEATHER BLACKALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2022
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2228 EDELWEISS LOOP
TRINITY FL
34655-4945
US

IV. Provider business mailing address

2228 EDELWEISS LOOP
TRINITY FL
34655-4945
US

V. Phone/Fax

Practice location:
  • Phone: 615-507-5194
  • Fax:
Mailing address:
  • Phone: 615-507-5194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-23-14396
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-67793
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: