Provider Demographics
NPI:1033874722
Name:BLACKBURN, EDWARD L
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25232 CODE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-5806
Mailing Address - Country:US
Mailing Address - Phone:248-867-9889
Mailing Address - Fax:
Practice Address - Street 1:25232 CODE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-5806
Practice Address - Country:US
Practice Address - Phone:248-409-4185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor