Provider Demographics
NPI:1366944167
Name:BLACKMAN, DUSTIN LEE (BCTMB, NCP, LMT)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:LEE
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:BCTMB, NCP, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:AL
Mailing Address - Zip Code:35674-2411
Mailing Address - Country:US
Mailing Address - Phone:256-200-9431
Mailing Address - Fax:
Practice Address - Street 1:103 W 5TH ST
Practice Address - Street 2:
Practice Address - City:TUSCUMBIA
Practice Address - State:AL
Practice Address - Zip Code:35674-2411
Practice Address - Country:US
Practice Address - Phone:256-200-9431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3081225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty