Provider Demographics
NPI:1750624326
Name:BLACKMON, RICHARD ALLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALLEN
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5655 LINDERO CANYON RD STE 621
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-4052
Mailing Address - Country:US
Mailing Address - Phone:818-889-1823
Mailing Address - Fax:
Practice Address - Street 1:5655 LINDERO CANYON RD STE 621
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-4052
Practice Address - Country:US
Practice Address - Phone:818-889-1823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical