Provider Demographics
NPI:1609442417
Name:BLACKMER, MAKAYLA
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:
Last Name:BLACKMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S WINMERE AVE
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:IN
Mailing Address - Zip Code:47383-9427
Mailing Address - Country:US
Mailing Address - Phone:765-748-8328
Mailing Address - Fax:
Practice Address - Street 1:500 S WINMERE AVE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:IN
Practice Address - Zip Code:47383-9427
Practice Address - Country:US
Practice Address - Phone:765-748-8328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2022-12-05
Deactivation Date:2022-11-15
Deactivation Code:
Reactivation Date:2022-11-22
Provider Licenses
StateLicense IDTaxonomies
INRBT-20-114191106S00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician