Provider Demographics
NPI:1538869672
Name:BLACKMON, CHELSIE
Entity type:Individual
Prefix:
First Name:CHELSIE
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 1:751 RHODEN COVE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-1013
Mailing Address - Country:US
Mailing Address - Phone:850-815-8800
Mailing Address - Fax:
Practice Address - Street 1:4816 COLORADO ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-6221
Practice Address - Country:US
Practice Address - Phone:850-554-9460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23261863106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician