Provider Demographics
NPI:1619254869
Name:BLACKMON, JOSHUA D (MED,CCC)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:D
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:MED,CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE A100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2114
Mailing Address - Country:US
Mailing Address - Phone:770-977-9457
Mailing Address - Fax:770-977-5087
Practice Address - Street 1:1000 JOHNSON FERRY RD
Practice Address - Street 2:SUITE A100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2114
Practice Address - Country:US
Practice Address - Phone:770-977-9457
Practice Address - Fax:770-977-5087
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007558235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist