Provider Demographics
NPI:1194866129
Name:BLACKSHEAR, ANGELA (SLP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BLACKSHEAR
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 1:150 LONG RD STE 150
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1237
Mailing Address - Country:US
Mailing Address - Phone:636-733-3330
Mailing Address - Fax:636-733-3332
Practice Address - Street 1:150 LONG RD STE 150
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1237
Practice Address - Country:US
Practice Address - Phone:636-733-3330
Practice Address - Fax:636-733-3332
Is Sole Proprietor?:No
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01057235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist