Provider Demographics
NPI:1477199115
Name:BLACKMON, ROWAN (LPC)
Entity Type:Individual
Prefix:MS
First Name:ROWAN
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BLUE MOON XING APT 7301
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-9756
Mailing Address - Country:US
Mailing Address - Phone:301-523-3220
Mailing Address - Fax:
Practice Address - Street 1:400 MAIN ST STE 200A-6
Practice Address - Street 2:
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29926-4610
Practice Address - Country:US
Practice Address - Phone:912-417-9541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011268101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health