=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700801933
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA ANDREA BLACKMAN MA CCC-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 RITTENHOUSE SQ C-1
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19103-5767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-985-4964
-----------------------------------------------------
Fax | 215-985-1678
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 RITTENHOUSE SQ C-1
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19103-5767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-985-4964
-----------------------------------------------------
Fax | 215-985-1678
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231HA2500X
-----------------------------------------------------
Taxonomy Name | Assistive Technology Supplier Audiologist
-----------------------------------------------------
License Number | AT000105L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------