Provider Demographics
NPI:1336495811
Name:BLACKMAN-JOHNSON, LYDIA CW
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:CW
Last Name:BLACKMAN-JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1483
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33970
Mailing Address - Country:US
Mailing Address - Phone:239-603-5425
Mailing Address - Fax:239-603-5425
Practice Address - Street 1:128 GORDAN AVENUE S.
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33973
Practice Address - Country:US
Practice Address - Phone:239-603-5425
Practice Address - Fax:239-603-5425
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684252679Medicaid