Provider Demographics
NPI:1114947009
Name:BLACKMUN, NANCY (PSYD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:BLACKMUN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 CENTRAL AVE APT B401
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-1366
Mailing Address - Country:US
Mailing Address - Phone:508-872-3568
Mailing Address - Fax:
Practice Address - Street 1:865 CENTRAL AVE APT B401
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-1366
Practice Address - Country:US
Practice Address - Phone:508-872-3568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3765103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03747Medicare PIN