Provider Demographics
NPI:1629686381
Name:BLACKLEDGE, COURTNEY BRIANN (LCMHCA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BRIANN
Last Name:BLACKLEDGE
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:910-343-0145
Mailing Address - Fax:910-202-9966
Practice Address - Street 1:110 PREMIERE PLZ
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-2522
Practice Address - Country:US
Practice Address - Phone:910-524-3812
Practice Address - Fax:910-202-9966
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15842101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty