Provider Demographics
NPI:1891896742
Name:BLACKFORD, JULIE ANN
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:BLACKFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:GILLISPIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:645 N JERICO ST
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-8963
Mailing Address - Country:US
Mailing Address - Phone:417-499-9276
Mailing Address - Fax:
Practice Address - Street 1:380 E HWY CC
Practice Address - Street 2:SUITE A105
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714
Practice Address - Country:US
Practice Address - Phone:417-725-8810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005038176101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional