Provider Demographics
NPI:1114071891
Name:BLACKBURN, MICHAEL (BA, RC, MFA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:BA, RC, MFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 SW HOLDEN ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-3505
Mailing Address - Country:US
Mailing Address - Phone:206-933-7299
Mailing Address - Fax:206-933-7250
Practice Address - Street 1:505 29TH ST SE
Practice Address - Street 2:CHARTLEY HOUSE
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-7541
Practice Address - Country:US
Practice Address - Phone:253-876-7650
Practice Address - Fax:253-876-7651
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00025589101YP2500X
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional