Healthcare Provider Details

I. General information

NPI: 1609796275
Provider Name (Legal Business Name): SHANTIA BLACKWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 BERGEN ST FL 1
BROOKLYN NY
11238-3405
US

IV. Provider business mailing address

640 MACDONOUGH ST APT 3B
BROOKLYN NY
11233-1358
US

V. Phone/Fax

Practice location:
  • Phone: 646-648-8877
  • Fax:
Mailing address:
  • Phone: 646-648-8877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number033898
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: