Provider Demographics
NPI:1083391593
Name:BLACKMAN, CHANDAL
Entity type:Individual
Prefix:
First Name:CHANDAL
Middle Name:
Last Name:BLACKMAN
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 1:812 E JOLLY RD STE 210
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-6821
Mailing Address - Country:US
Mailing Address - Phone:517-237-7350
Mailing Address - Fax:517-346-8291
Practice Address - Street 1:812 E JOLLY RD STE 110
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-6820
Practice Address - Country:US
Practice Address - Phone:517-346-8318
Practice Address - Fax:517-237-7270
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511178871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical