Provider Demographics
NPI:1114500196
Name:BLACKSHEAR, AMBER B (LCSW)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:B
Last Name:BLACKSHEAR
Suffix:
Gender:F
Credentials:LCSW
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 267
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-0267
Mailing Address - Country:US
Mailing Address - Phone:601-988-3340
Mailing Address - Fax:
Practice Address - Street 1:1316 ARMAND DR APT 304
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-8974
Practice Address - Country:US
Practice Address - Phone:601-988-3340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618381041C0700X
TN76271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty