MEDICARE: HAROLD DANIEL BLACKWOOD PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	689	AZ

General Provider Information

NPI Number	:	1215086137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAROLD DANIEL BLACKWOOD PHD

Provider Business Mailing Address
First Line	:	6232 N 7TH ST
Second Line	:	STE 100
City	:	PHOENIX
State	:	AZ
Zip	:	85014-1839
Country	:	US
Telephone Number	:	602-230-8324
Fax Number	:	602-274-7402

Provider Business Practice Location Address
First Line	:	6232 N 7TH ST
Second Line	:	STE 100
City	:	PHOENIX
State	:	AZ
Zip	:	85014-1839
Country	:	US
Telephone Number	:	602-230-8324
Fax Number	:	602-274-7402

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	02/05/2010

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