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NPI Code Detail

MEDICARE: EBONY LASHA BLACKMON

MEDICARE: EBONY LASHA 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
1106S00000XBehavior TechnicianNC

General Provider Information

NPI Number : 1669967089
Entity Type Code : Individual
Provider Name (Legal Business Name) : EBONY LASHA BLACKMON
Provider Business Mailing Address
First Line : 3308 REHOBETH CHURCH RD APT Q
Second Line :
City : GREENSBORO
State : NC
Zip : 27406-5038
Country : US
Telephone Number : 336-987-9895
Fax Number :
Provider Business Practice Location Address
First Line : 1401 E 7TH ST STE 100
Second Line :
City : CHARLOTTE
State : NC
Zip : 28204-6301
Country : US
Telephone Number : 704-780-4271
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/27/2018
Last Update Date : 06/27/2018

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Directions to “ EBONY LASHA BLACKMON ” Practice Location

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