Provider Demographics
NPI:1558602219
Name:BLACKMON, SHARON (LMT)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 MOUNT ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46406-1615
Mailing Address - Country:US
Mailing Address - Phone:219-944-1948
Mailing Address - Fax:
Practice Address - Street 1:3329 VOLLMER RD
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2003
Practice Address - Country:US
Practice Address - Phone:708-206-2750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.008299225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist