Provider Demographics
NPI:1083747224
Name:BLACKMON, KIMBERLY ANNE (LPC, NCC, LCAS, CCS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:LPC, NCC, LCAS, CCS
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCS, LCAS, CCS, NCC
Mailing Address - Street 1:12631 BULLOCK GREENWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-8177
Mailing Address - Country:US
Mailing Address - Phone:980-245-8433
Mailing Address - Fax:
Practice Address - Street 1:429 BILLINGSLEY RD
Practice Address - Street 2:MECKLENBURG COUNTY AMH SASC
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1007
Practice Address - Country:US
Practice Address - Phone:704-336-5651
Practice Address - Fax:704-336-5105
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3706S101YP2500X
NC398101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102838Medicaid