Healthcare Provider Details

I. General information

NPI: 1114332038
Provider Name (Legal Business Name): AIMEE BLACKHAM PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 BURGESSVILLE RD
RUSTON LA
71270-5154
US

IV. Provider business mailing address

3506 EVELYN CIR
RUSTON LA
71270-5323
US

V. Phone/Fax

Practice location:
  • Phone: 318-224-7223
  • Fax: 318-414-1004
Mailing address:
  • Phone: 318-243-0465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1373
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: