Provider Demographics
NPI:1063179547
Name:BLACKMON, LATREASA DENISE (LPC)
Entity type:Individual
Prefix:MRS
First Name:LATREASA
Middle Name:DENISE
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E OGDEN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-3264
Mailing Address - Country:US
Mailing Address - Phone:331-444-2342
Mailing Address - Fax:
Practice Address - Street 1:500 E OGDEN AVE STE 101
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-3264
Practice Address - Country:US
Practice Address - Phone:331-444-2342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178017570101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor