Provider Demographics
NPI:1629116751
Name:BLACKMAN, MIKKI G (MSW)
Entity Type:Individual
Prefix:MS
First Name:MIKKI
Middle Name:G
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:MIKKI
Other - Middle Name:
Other - Last Name:BLACKMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:108 RUTHERFORD ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483
Mailing Address - Country:US
Mailing Address - Phone:843-437-5994
Mailing Address - Fax:843-875-2189
Practice Address - Street 1:108 RUTHERFORD ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483
Practice Address - Country:US
Practice Address - Phone:843-437-5994
Practice Address - Fax:843-875-2189
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0023871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q269480281Medicare ID - Type Unspecified