Provider Demographics
NPI:1295292274
Name:BLACKLEDGE, CARROLL D (MA, P-LPC)
Entity type:Individual
Prefix:
First Name:CARROLL
Middle Name:D
Last Name:BLACKLEDGE
Suffix:
Gender:M
Credentials:MA, P-LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 LAUREL GLEN CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7395
Mailing Address - Country:US
Mailing Address - Phone:601-622-7277
Mailing Address - Fax:
Practice Address - Street 1:4500 I 55 N STE 208
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5931
Practice Address - Country:US
Practice Address - Phone:601-405-7440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0512101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional