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1740282110

NPI Code Detail

MEDICARE: DR. MILDRED L BLACKFORD PHD

MEDICARE: DR. MILDRED L BLACKFORD PHD

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	20040561A	IN
2	103TC0700X	Clinical Psychologist	20040531A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	148297000	OTHER	IN	MAGELLAN
2	226467	OTHER	IN	MHN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	11383545	OTHER	IN	CAQH
5	000000182274	OTHER	IN	BCBS
6	000000006038	OTHER	IN	MPLAN

General Provider Information

NPI Number	:	1740282110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MILDRED L BLACKFORD PHD

Provider Business Mailing Address
First Line	:	250 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 N MAIN ST # 304
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-1877
Country	:	US
Telephone Number	:	574-546-1900
Fax Number	:	574-546-1999

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	07/10/2024

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Directions to “ DR. MILDRED L BLACKFORD PHD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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