Provider Demographics
NPI:1609233907
Name:BLACKMAN, PETER RUSSELL JR
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:RUSSELL
Last Name:BLACKMAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 VALLEY STREET PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:MANSURA
Mailing Address - State:LA
Mailing Address - Zip Code:71350-0205
Mailing Address - Country:US
Mailing Address - Phone:318-346-8001
Mailing Address - Fax:318-346-8005
Practice Address - Street 1:1140 SHIRLEY RD
Practice Address - Street 2:
Practice Address - City:BUNKIE
Practice Address - State:LA
Practice Address - Zip Code:71322-1545
Practice Address - Country:US
Practice Address - Phone:318-346-8001
Practice Address - Fax:318-346-8005
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1544761101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1544761Medicaid