Provider Demographics
NPI:1114332038
Name:BLACKHAM, AIMEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:AIMEE
Middle Name:
Last Name:BLACKHAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 EVELYN CIR
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5323
Mailing Address - Country:US
Mailing Address - Phone:318-243-0465
Mailing Address - Fax:
Practice Address - Street 1:617 S TRENTON ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5040
Practice Address - Country:US
Practice Address - Phone:318-251-4659
Practice Address - Fax:318-251-4659
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1373103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA567123890Medicaid