Healthcare Provider Details

I. General information

NPI: 1548038532
Provider Name (Legal Business Name): REBECCA LYNN BLACKWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2023
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2388 UNIVERSITY AVE W STE 202
SAINT PAUL MN
55114-1769
US

IV. Provider business mailing address

2935 FREMONT AVE S APT 305
MINNEAPOLIS MN
55408-2089
US

V. Phone/Fax

Practice location:
  • Phone: 800-945-2401
  • Fax:
Mailing address:
  • Phone: 502-419-5964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: