Healthcare Provider Details

I. General information

NPI: 1538318183
Provider Name (Legal Business Name): LESA N BLACKHURST M.S., CCC, SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 N ILLINOIS ST STE 445
CARMEL IN
46032-3010
US

IV. Provider business mailing address

9002 N MERIDIAN ST STE 222
INDIANAPOLIS IN
46260-5350
US

V. Phone/Fax

Practice location:
  • Phone: 317-844-7059
  • Fax: 317-573-4352
Mailing address:
  • Phone: 317-573-4370
  • Fax: 317-819-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number22003848A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22003848A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: