Provider Demographics
NPI:1053457671
Name:BLACKBURN, KATHERINE A (MA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 FENTON MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2309
Mailing Address - Country:US
Mailing Address - Phone:314-550-4307
Mailing Address - Fax:636-343-3697
Practice Address - Street 1:1275 FENTON MEADOW CT
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2309
Practice Address - Country:US
Practice Address - Phone:314-550-4307
Practice Address - Fax:636-343-3697
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110917235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist