Provider Demographics
NPI:1467753178
Name:BLACKMAN, MUMINA (MED)
Entity Type:Individual
Prefix:MS
First Name:MUMINA
Middle Name:
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5170 E 65TH ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4892
Mailing Address - Country:US
Mailing Address - Phone:317-223-6057
Mailing Address - Fax:317-845-8476
Practice Address - Street 1:5170 E. 65TH STREET
Practice Address - Street 2:SUITE 107
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220
Practice Address - Country:US
Practice Address - Phone:317-223-6057
Practice Address - Fax:317-845-8476
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health