Provider Demographics
NPI:1477762052
Name:BLACKMON, WILLIE LARRY (LCPC; CADC; MA)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:LARRY
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:LCPC; CADC; MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5834 S MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-1124
Mailing Address - Country:US
Mailing Address - Phone:773-778-4835
Mailing Address - Fax:773-778-4835
Practice Address - Street 1:17504 E CARRIAGEWAY DR STE B
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2089
Practice Address - Country:US
Practice Address - Phone:708-799-0300
Practice Address - Fax:708-799-0300
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5848101YA0400X
IL178-002766101YM0800X
IL180.007189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health