Provider Demographics
NPI:1407474919
Name:BLACKMON, ABSALOM (RKT, LMT,MMP,CPS)
Entity Type:Individual
Prefix:MR
First Name:ABSALOM
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:RKT, LMT,MMP,CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4822 RIVER VISTA LN APT B
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-7589
Mailing Address - Country:US
Mailing Address - Phone:601-874-8542
Mailing Address - Fax:
Practice Address - Street 1:4822 RIVER VISTA LN APT B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-7589
Practice Address - Country:US
Practice Address - Phone:601-874-8542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227022111225700000X
IL2055226300000X
FL2055226300000X
FLMA100038225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist