Provider Demographics
NPI:1396367405
Name:BLACKMAN, CARESSA (CTRS)
Entity Type:Individual
Prefix:
First Name:CARESSA
Middle Name:
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-4059
Mailing Address - Country:US
Mailing Address - Phone:903-583-1405
Mailing Address - Fax:
Practice Address - Street 1:4820 CHRISTIE AVE
Practice Address - Street 2:
Practice Address - City:CADDO MILLS
Practice Address - State:TX
Practice Address - Zip Code:75135
Practice Address - Country:US
Practice Address - Phone:843-476-3460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist