Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | 1373 | LA |
NPI | 1114332038 |
---|---|
Provider Name | Dr. Aimee Blackham |
First Address | Ruston, LA 71270-5323 |
Second Address | Ruston, LA 71270-5040 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2014 |
Last Update Date | 30/09/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
567123890 | (05) | LA |