1083747224 NPI number — KIMBERLY ANNE BLACKMON LPC, NCC, LCAS, CCS

Table of content: KIMBERLY ANNE BLACKMON LPC, NCC, LCAS, CCS (NPI 1083747224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083747224 NPI number — KIMBERLY ANNE BLACKMON LPC, NCC, LCAS, CCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKMON
Provider First Name:
KIMBERLY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, NCC, LCAS, CCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PHILLIPS
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPCS, LCAS, CCS, NCC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083747224
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12631 BULLOCK GREENWAY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28277-8177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
980-245-8433
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
429 BILLINGSLEY RD
Provider Second Line Business Practice Location Address:
MECKLENBURG COUNTY AMH SASC
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28211-1007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-336-5651
Provider Business Practice Location Address Fax Number:
704-336-5105
Provider Enumeration Date:
03/14/2007

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: 101YP2500X , with the licence number:  3706S , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 398 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6102838 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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