Provider Demographics
NPI:1144338211
Name:BLACKMON, DAVID (PHD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 A1A N STE 325
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-1826
Mailing Address - Country:US
Mailing Address - Phone:904-333-3389
Mailing Address - Fax:904-713-2989
Practice Address - Street 1:330 A1A N STE 325
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-1826
Practice Address - Country:US
Practice Address - Phone:904-333-3389
Practice Address - Fax:904-713-2989
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004360103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54401Medicare ID - Type Unspecified