| Doctor Name: | MR. PETER RUSSELL BLACKMAN |
| NPI Number: | 1609233907 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 1544761 |
| Business Practice Address: | 1140 Shirley Rd Bunkie, LA - 713221545 |
| Business Phone Number: | 3183468001 |
| Business Fax Number: | 3183468005 |
| Mailing Address: | 2260 Valley Street Po Box 205, MANSURA |
| State: | LA |
| Postal Code: | 713500205 |
| Phone Number: | 3183468001 |
| Fax Number: | 3183468005 |
| NPI Enumeration Date: | 01/19/2016 |
| NPI Last Update Date: | 01/19/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | 1544761 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | LA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |