Provider Demographics
NPI:1831893106
Name:BLACKMON, ALEXIS (LMSW)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:HEALED
Other - Middle Name:
Other - Last Name:GRACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4405 MALL BLVD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-2044
Mailing Address - Country:US
Mailing Address - Phone:000-000-0000
Mailing Address - Fax:
Practice Address - Street 1:1444 FENWICK DR SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2779
Practice Address - Country:US
Practice Address - Phone:678-561-3868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW010705104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty