Provider Demographics
NPI:1689302432
Name:BLACKSON, MELISSA SHEREE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SHEREE
Last Name:BLACKSON
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 1:8122 STONELAKE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70820-8754
Mailing Address - Country:US
Mailing Address - Phone:318-282-6814
Mailing Address - Fax:
Practice Address - Street 1:7800 INNOVATION PARK DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70820-7008
Practice Address - Country:US
Practice Address - Phone:225-953-7963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC9233101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health