Healthcare Provider Details

I. General information

NPI: 1891605390
Provider Name (Legal Business Name): CHARLOTTE PAIGE BLACKMON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 ANTIOCH CHURCH RD
MATTHEWS NC
28104-5484
US

IV. Provider business mailing address

3101 ANTIOCH CHURCH RD
MATTHEWS NC
28104-5484
US

V. Phone/Fax

Practice location:
  • Phone: 704-296-3005
  • Fax:
Mailing address:
  • Phone: 704-296-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30005571
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: