Provider Demographics
NPI:1659802072
Name:BLACKMON, REGINALD SR
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:BLACKMON
Suffix:SR
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 1:221 N CEDAR ST APT D
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-1302
Mailing Address - Country:US
Mailing Address - Phone:704-620-0555
Mailing Address - Fax:
Practice Address - Street 1:525 NORTH TRYON STREET
Practice Address - Street 2:SUITE 1636
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202
Practice Address - Country:US
Practice Address - Phone:704-620-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral