Provider Demographics
NPI:1770339756
Name:BLACKWELL, DERRIEK (CSW)
Entity type:Individual
Prefix:
First Name:DERRIEK
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5663 S REDWOOD RD
Mailing Address - Street 2:SUITE 2, OFFICE 10
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123
Mailing Address - Country:US
Mailing Address - Phone:801-742-5851
Mailing Address - Fax:
Practice Address - Street 1:5663 S REDWOOD RD
Practice Address - Street 2:SUITE 2, OFFICE 10
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123
Practice Address - Country:US
Practice Address - Phone:801-742-5851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13844125-3502101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health