Provider Demographics
NPI:1841833043
Name:BLACKMON, ARY
Entity type:Individual
Prefix:
First Name:ARY
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20239 BUR OAK DR
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-5351
Mailing Address - Country:US
Mailing Address - Phone:818-438-5326
Mailing Address - Fax:
Practice Address - Street 1:146 MCGEHEE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-5012
Practice Address - Country:US
Practice Address - Phone:225-275-7273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5326Medicaid