MEDICARE: DR. LISA R BLACKMAN PH.D.

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	103TC0700X	Clinical Psychologist		IL

General Provider Information

NPI Number	:	1255323838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA R BLACKMAN PH.D.

Provider Business Mailing Address
First Line	:	314 MDOS/ SGOH
Second Line	:	1090 ARNOLD DRIVE
City	:	LITTLE ROCK AFB
State	:	AR
Zip	:	72099
Country	:	US
Telephone Number	:	501-987-7338
Fax Number	:	501-987-8087

Provider Business Practice Location Address
First Line	:	314 MDOS/ SGOH
Second Line	:	1090 ARNOLD DRIVE
City	:	LITTLE ROCK AFB
State	:	AR
Zip	:	72099-0001
Country	:	US
Telephone Number	:	501-987-7338
Fax Number	:	501-987-8087

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	09/17/2007

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