Provider Demographics
NPI:1053780627
Name:BLACKBURN, TRICIA
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:#M131
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-6233
Mailing Address - Country:US
Mailing Address - Phone:330-844-1751
Mailing Address - Fax:
Practice Address - Street 1:2750 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:#M131
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-6233
Practice Address - Country:US
Practice Address - Phone:330-844-1751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL58755235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist