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General NPI Number Information
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NPI Number | 1336495811
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Entity Type | Individual
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Provider Name | LYDIA C.W. BLACKMAN-JOHNSON
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Gender | Female
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Dates
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Enumeration Date | 08/02/2012
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Last Update Date | 08/02/2012
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Provider Practice Location Address
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Address Line | 128 GORDAN AVENUE S.
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City | LEHIGH ACRES
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State | FL
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Zip | 33973
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Country | US
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Telephone | 239-603-5425
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Fax | 239-603-5425
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Provider Business Mailing Address
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Address Line | P.O. BOX 1483
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City | LEHIGH ACRES
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State | FL
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Zip | 33970
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Country | US
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Telephone | 239-603-5425
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Fax | 239-603-5425
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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