Provider Demographics
NPI:1447714332
Name:BLACKMON, STACIA
Entity type:Individual
Prefix:
First Name:STACIA
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 1:3932 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2807
Mailing Address - Country:US
Mailing Address - Phone:850-434-7755
Mailing Address - Fax:850-469-0858
Practice Address - Street 1:3932 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2807
Practice Address - Country:US
Practice Address - Phone:854-434-7755
Practice Address - Fax:850-469-0858
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist