Basic Information
| Provider Information | |||||||||
| NPI: | 1720691322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKWELL | ||||||||
| FirstName: | CHELSEA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9038 CROSS PARK DR STE 105 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653946612 | ||||||||
| FaxNumber: | 8653157014 | ||||||||
| Practice Location | |||||||||
| Address1: | 9038 CROSS PARK DR STE 105 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653946612 | ||||||||
| FaxNumber: | 8653157014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2020 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | LABA25 | TN | N | 106E00000X | 0-20-11075 | IN | N | 103K00000X | LBA799 | TN | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | LABA25 | 01 | TN | STATE OF TN | OTHER | 0-20-11075 | 01 | IN | BACB | OTHER | LBA799 | 01 | TN | STATE OF TN | OTHER |