Provider Demographics
NPI:1053893198
Name:BLACKBURN, MARY ELIZABETH (MASTERS IN SPEC ED)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MASTERS IN SPEC ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 W COUNTY ROAD 500 N
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-8662
Mailing Address - Country:US
Mailing Address - Phone:260-330-4450
Mailing Address - Fax:
Practice Address - Street 1:168 W COUNTY ROAD 500 N
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-8662
Practice Address - Country:US
Practice Address - Phone:260-330-4450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty