Provider Demographics
NPI:1003957697
Name:BLACKBURN, DANA (LICSW)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 CENTER ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-3063
Mailing Address - Country:US
Mailing Address - Phone:413-584-1766
Mailing Address - Fax:
Practice Address - Street 1:43 CENTER ST
Practice Address - Street 2:SUITE 204
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3063
Practice Address - Country:US
Practice Address - Phone:413-584-1766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10258031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07168Medicare ID - Type Unspecified