Provider Demographics
NPI:1306253067
Name:HEATHER BLACKMORE MA LMFTA
Entity type:Organization
Organization Name:HEATHER BLACKMORE MA LMFTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BLACKMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MA LMFTA
Authorized Official - Phone:360-649-1238
Mailing Address - Street 1:374 NE MAX WILLIAM LOOP
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-9169
Mailing Address - Country:US
Mailing Address - Phone:360-649-1238
Mailing Address - Fax:
Practice Address - Street 1:374 NE MAX WILLIAM LOOP
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370
Practice Address - Country:US
Practice Address - Phone:360-649-1238
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG60354376261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health