Provider Demographics
NPI:1164987129
Name:BLACKFORD, CONNIE FAYE (MA, CCC-SP)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:FAYE
Last Name:BLACKFORD
Suffix:
Gender:F
Credentials:MA, CCC-SP
Other - Prefix:MISS
Other - First Name:CONNIE
Other - Middle Name:FAYE
Other - Last Name:LAUTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:607 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-1356
Mailing Address - Country:US
Mailing Address - Phone:812-453-4649
Mailing Address - Fax:
Practice Address - Street 1:607 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-1356
Practice Address - Country:US
Practice Address - Phone:812-453-4649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22001775A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00117481OtherASHA - CCC-SLP
IN22001775AOtherIPLA - SPEECH PATHOLOGIST LICENSE