Provider Demographics
NPI:1114277662
Name:BLACKBURN, MICHAEL TODD (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TODD
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 4TH ST NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-5020
Mailing Address - Country:US
Mailing Address - Phone:253-931-4927
Mailing Address - Fax:253-931-4742
Practice Address - Street 1:502 4TH ST NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-5020
Practice Address - Country:US
Practice Address - Phone:253-931-4927
Practice Address - Fax:253-931-4742
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA415854R235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist