Provider Demographics
NPI:1164249058
Name:BLACKETER, CYNETHA ANN (MS)
Entity type:Individual
Prefix:MS
First Name:CYNETHA
Middle Name:ANN
Last Name:BLACKETER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:CYNETHA
Other - Middle Name:ANN
Other - Last Name:DANIEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:601 WOODDUCK DR SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-2672
Mailing Address - Country:US
Mailing Address - Phone:360-556-5269
Mailing Address - Fax:
Practice Address - Street 1:1534 BISHOP RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7354
Practice Address - Country:US
Practice Address - Phone:360-357-2370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist