Provider Demographics
NPI:1003162827
Name:BLACKBURN, LAURA (MSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8425 N LAKE DR
Mailing Address - Street 2:APT F
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-3403
Mailing Address - Country:US
Mailing Address - Phone:847-636-1159
Mailing Address - Fax:847-636-1159
Practice Address - Street 1:8425 N LAKE DR
Practice Address - Street 2:APT F
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-3403
Practice Address - Country:US
Practice Address - Phone:847-636-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health