Provider Demographics
NPI:1033683529
Name:BLACKBURN, WILLIAM KELLY (MASSAGE THERAPY)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KELLY
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MASSAGE THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 NW GILMAN BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2454
Mailing Address - Country:US
Mailing Address - Phone:941-276-5651
Mailing Address - Fax:
Practice Address - Street 1:24620 RUSSELL RD APT D102
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-4745
Practice Address - Country:US
Practice Address - Phone:941-276-5651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60751082225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist