MEDICARE: LYNETTE BUSH BLACKWELL

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	106S00000X	Behavior Technician		NY

General Provider Information

NPI Number	:	1508303116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNETTE BUSH BLACKWELL

Provider Business Mailing Address
First Line	:	11 WILLOW ST
Second Line	:
City	:	WHEATLEY HEIGHTS
State	:	NY
Zip	:	11798-1829
Country	:	US
Telephone Number	:	631-920-6542
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 WILLOW ST
Second Line	:
City	:	WHEATLEY HEIGHTS
State	:	NY
Zip	:	11798-1829
Country	:	US
Telephone Number	:	631-920-6542
Fax Number	:

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

Provider Enumeration Date	:	01/21/2017
Last Update Date	:	01/21/2017

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Directions to “ LYNETTE BUSH BLACKWELL ” Practice Location

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