Provider Demographics
NPI:1427154699
Name:BLACKMON, PAMELA STUCKEY (CSAC)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:STUCKEY
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12504 SUSANNA DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-6490
Mailing Address - Country:US
Mailing Address - Phone:704-562-9414
Mailing Address - Fax:
Practice Address - Street 1:5601 EXECUTIVE CENTER DR STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8841
Practice Address - Country:US
Practice Address - Phone:704-561-0920
Practice Address - Fax:704-561-0851
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1879101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)