Healthcare Provider Details

I. General information

NPI: 1194752576
Provider Name (Legal Business Name): LAUREL EVE BLACKMAN D.O., M.B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 GLEN COVE DR
ROCKPORT ME
04856-4272
US

IV. Provider business mailing address

3312 GLENVIEW AVE
AUSTIN TX
78703-1447
US

V. Phone/Fax

Practice location:
  • Phone: 512-228-2441
  • Fax:
Mailing address:
  • Phone: 512-228-2441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number054073
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberBP10023295
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM4715
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO2515
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: