Healthcare Provider Details

I. General information

NPI: 1851219935
Provider Name (Legal Business Name): NICOLAS BLACKMAN LCPC-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GANNETT DR STE A
SOUTH PORTLAND ME
04106-5900
US

IV. Provider business mailing address

100 GANNETT DR STE A
SOUTH PORTLAND ME
04106-5900
US

V. Phone/Fax

Practice location:
  • Phone: 207-742-8558
  • Fax:
Mailing address:
  • Phone: 207-742-8558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberXL8162
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: