Provider Demographics
NPI:1073666012
Name:BLACKBURN, KERRY D (LICSW)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:D
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 SW 152ND ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1843
Mailing Address - Country:US
Mailing Address - Phone:206-431-3171
Mailing Address - Fax:206-242-7330
Practice Address - Street 1:929 SW 152ND ST
Practice Address - Street 2:SUITE D
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1843
Practice Address - Country:US
Practice Address - Phone:206-431-3171
Practice Address - Fax:206-242-7330
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000057591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical