Provider Demographics
NPI:1134249279
Name:BLACKMON, LATISHA ANN
Entity type:Individual
Prefix:MRS
First Name:LATISHA
Middle Name:ANN
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 1:4032 E CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-2519
Mailing Address - Country:US
Mailing Address - Phone:559-477-0289
Mailing Address - Fax:
Practice Address - Street 1:4032 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-2519
Practice Address - Country:US
Practice Address - Phone:559-265-4800
Practice Address - Fax:559-265-4823
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)