Provider Demographics
NPI:1053505024
Name:BLACKMAN, TREVA (SLP)
Entity Type:Individual
Prefix:
First Name:TREVA
Middle Name:
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 535217
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75053-5217
Mailing Address - Country:US
Mailing Address - Phone:817-299-9200
Mailing Address - Fax:817-299-9222
Practice Address - Street 1:915 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-4924
Practice Address - Country:US
Practice Address - Phone:817-299-9200
Practice Address - Fax:817-299-9222
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14970235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist