Provider Demographics
NPI:1902448491
Name:BLACKMON, HAYLEE KRISTOFER
Entity Type:Individual
Prefix:
First Name:HAYLEE
Middle Name:KRISTOFER
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HAYLEE
Other - Middle Name:KRISTOFER
Other - Last Name:BLACKMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:306 WYNN DR NW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805-1961
Mailing Address - Country:US
Mailing Address - Phone:256-326-9358
Mailing Address - Fax:
Practice Address - Street 1:306 WYNN DR NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-1961
Practice Address - Country:US
Practice Address - Phone:256-326-9358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19-96132106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician