Provider Demographics
NPI:1417489774
Name:BLACKMON, LEE
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5003 S MIAMI BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-8589
Mailing Address - Country:US
Mailing Address - Phone:919-354-0840
Mailing Address - Fax:877-840-6694
Practice Address - Street 1:580 W 8TH ST
Practice Address - Street 2:6TH FLOOR, SUITE 6005
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6533
Practice Address - Country:US
Practice Address - Phone:904-244-3990
Practice Address - Fax:904-244-3455
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC863922084P0800X
390200000X
NC2021006032084P0800X
FLTRN24684390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program