MEDICARE: MRS. LATISHA ANN BLACKMON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1134249279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LATISHA ANN BLACKMON

Provider Business Mailing Address
First Line	:	4032 E CLINTON AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93703-2519
Country	:	US
Telephone Number	:	559-477-0289
Fax Number	:

Provider Business Practice Location Address
First Line	:	4032 E CLINTON AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93703-2519
Country	:	US
Telephone Number	:	559-265-4800
Fax Number	:	559-265-4823

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	07/08/2007

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