Basic Information
| Provider Information | |||||||||
| NPI: | 1336316470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKMAN | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 902 SHANGHAI RD | ||||||||
| Address2: | |||||||||
| City: | BALL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714053348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187290389 | ||||||||
| FaxNumber: | 3184456503 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 SHANGHAI RD | ||||||||
| Address2: | |||||||||
| City: | BALL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714053348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187290389 | ||||||||
| FaxNumber: | 3184456503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2008 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 993 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1457529349 | 01 | NPI - COMPASSIONATE COUNSELING CENTER, L.L.C. | OTHER |