1538318183 NPI number — LESA N BLACKHURST M.S., CCC, SLP

Table of content: LESA N BLACKHURST M.S., CCC, SLP (NPI 1538318183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538318183 NPI number — LESA N BLACKHURST M.S., CCC, SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKHURST
Provider First Name:
LESA
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC, SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538318183
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9002 N MERIDIAN ST
Provider Second Line Business Mailing Address:
STE 222
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46260-5350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-573-4370
Provider Business Mailing Address Fax Number:
317-819-0044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11725 N ILLINOIS ST
Provider Second Line Business Practice Location Address:
STE 445
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46032-3010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-844-7059
Provider Business Practice Location Address Fax Number:
317-573-4352
Provider Enumeration Date:
09/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  22003848A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 22003848A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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