=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720147119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLEY M BLACKWELL LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2006
-----------------------------------------------------
Last Update Date | 06/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 795 HOLLY LN
-----------------------------------------------------
City | WAVERLY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-296-9813
-----------------------------------------------------
Fax | 931-296-9853
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 795 HOLLY LN
-----------------------------------------------------
City | WAVERLY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37185-3392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-296-9813
-----------------------------------------------------
Fax | 931-296-9853
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 567
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------