Provider Demographics
NPI:1932653482
Name:BLACKMON, NICHOLE (LPC)
Entity Type:Individual
Prefix:MISS
First Name:NICHOLE
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 BROOKS DR
Mailing Address - Street 2:APARTMENT 404
Mailing Address - City:FORESTVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20747-1064
Mailing Address - Country:US
Mailing Address - Phone:202-431-6266
Mailing Address - Fax:
Practice Address - Street 1:2110 BROOKS DR
Practice Address - Street 2:APARTMENT 404
Practice Address - City:FORESTVILLE
Practice Address - State:MD
Practice Address - Zip Code:20747-1064
Practice Address - Country:US
Practice Address - Phone:202-431-6266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6529101YP2500X
DCPRC14727101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional