Provider Demographics
NPI:1598752792
Name:BLAKEMORE, CAROL WARREN (MBA, LCSW, APRN, BC)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:WARREN
Last Name:BLAKEMORE
Suffix:
Gender:F
Credentials:MBA, LCSW, APRN, BC
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:L
Other - Last Name:WARREN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:9160 VALLEY GROVE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9107
Mailing Address - Country:US
Mailing Address - Phone:662-393-5671
Mailing Address - Fax:
Practice Address - Street 1:920 MADISON
Practice Address - Street 2:STE. 507
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-0001
Practice Address - Country:US
Practice Address - Phone:901-448-1584
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6671041C0700X
TN67375163WP0809X
TN364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Not Answered364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult