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General NPI Number Information
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NPI Number | 1154754547
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Entity Type | Organization
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Legal Business Name | BLACKMON COUNSELING SERVICES
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Dates
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Enumeration Date | 08/20/2013
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Last Update Date | 08/20/2013
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Provider Practice Location Address
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Address Line | 5834 S MAPLEWOOD AVE
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City | CHICAGO
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State | IL
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Zip | 60629-1124
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Country | US
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Telephone | 773-778-4835
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Fax |
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Provider Business Mailing Address
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Address Line | 5834 S MAPLEWOOD AVE
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City | CHICAGO
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State | IL
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Zip | 60629-1124
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Country | US
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Telephone | 773-778-4835
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Fax |
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Authorized Official
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Title or Position | LICENSED PROFESSIONAL COUNSELOR
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Name | WILLIE L BLACKMON
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Credential | LCPC MA
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Telephone | 773-934-5668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 180.007189
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License Number State | IL
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