Provider Demographics
NPI:1992853063
Name:BLACKMORE, WALISHA M (M ED, LPC-S)
Entity Type:Individual
Prefix:
First Name:WALISHA
Middle Name:M
Last Name:BLACKMORE
Suffix:
Gender:F
Credentials:M ED, LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 19TH STREET
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640
Mailing Address - Country:US
Mailing Address - Phone:409-344-2790
Mailing Address - Fax:
Practice Address - Street 1:2512 NALL ST
Practice Address - Street 2:
Practice Address - City:PORT NECHES
Practice Address - State:TX
Practice Address - Zip Code:77651-4706
Practice Address - Country:US
Practice Address - Phone:409-727-5785
Practice Address - Fax:409-729-0465
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15296101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0283715-03Medicaid