Provider Demographics
NPI:1891286472
Name:BLACKMORE, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BLACKMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:LOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8512 W HERSHEY RD
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:61062-9571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8512 W HERSHEY RD
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:IL
Practice Address - Zip Code:61062-9571
Practice Address - Country:US
Practice Address - Phone:815-275-8134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-19
Last Update Date:2018-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17-46456106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician