Healthcare Provider Details

I. General information

NPI: 1679439475
Provider Name (Legal Business Name): DERICA BLACKMON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2025
Last Update Date: 01/04/2026
Certification Date: 01/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 W POPLAR ST
MC GEHEE AR
71654-2548
US

IV. Provider business mailing address

307 W POPLAR ST
MC GEHEE AR
71654-2548
US

V. Phone/Fax

Practice location:
  • Phone: 870-222-7314
  • Fax:
Mailing address:
  • Phone: 870-222-7314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26359-M
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number26359-M
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: