Provider Demographics
NPI:1154610103
Name:BLACKMON, BILL NEFF JR
Entity type:Individual
Prefix:
First Name:BILL
Middle Name:NEFF
Last Name:BLACKMON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BILL
Other - Middle Name:NEFF
Other - Last Name:BLACKMON
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:3508 ANDOVER DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-2926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3508 ANDOVER DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-2926
Practice Address - Country:US
Practice Address - Phone:817-781-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2062106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist