Healthcare Provider Details

I. General information

NPI: 1366707788
Provider Name (Legal Business Name): RICHARD THOMAS BLACKWELL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2813 COLTSGATE RD SUITE 201
CHARLOTTE NC
28211-3798
US

IV. Provider business mailing address

2813 COLTSGATE RD SUITE 201
CHARLOTTE NC
28211-3798
US

V. Phone/Fax

Practice location:
  • Phone: 704-491-9646
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1628
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: