Provider Demographics
NPI:1043411903
Name:BLACKMON-IMAR, DENISE
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:
Last Name:BLACKMON-IMAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4319 CANADIAN RIVER DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-5401
Mailing Address - Country:US
Mailing Address - Phone:281-265-8967
Mailing Address - Fax:281-265-8967
Practice Address - Street 1:4319 CANADIAN RIVER DR
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-5401
Practice Address - Country:US
Practice Address - Phone:281-265-8967
Practice Address - Fax:281-265-8967
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator