1790170892 NPI number — SADE BLACKSHEAR LMHC

Table of content: SADE BLACKSHEAR LMHC (NPI 1790170892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790170892 NPI number — SADE BLACKSHEAR LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKSHEAR
Provider First Name:
SADE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMHC
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:
1790170892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2110 LINDA SUE CIR APT 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT PIERCE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34982-2100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-216-3270
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 SE FEDERAL HWY STE 334
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994-3839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-690-6906
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2015

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: 101YM0800X , with the licence number:  MH15693 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 108212600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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