Provider Demographics
NPI:1760195481
Name:BLACKMON, TARAE (SUDP)
Entity Type:Individual
Prefix:
First Name:TARAE
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6536 A ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-7308
Mailing Address - Country:US
Mailing Address - Phone:253-754-7389
Mailing Address - Fax:
Practice Address - Street 1:721 FAWCETT AVE STE 204
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5502
Practice Address - Country:US
Practice Address - Phone:253-389-3383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)