Provider Demographics
NPI:1114947009
Name:BLACKMUN, NANCY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:BLACKMUN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 N. MAIN STREET
Mailing Address - Street 2:STE255
Mailing Address - City:SHERBORN
Mailing Address - State:MA
Mailing Address - Zip Code:01770-1500
Mailing Address - Country:US
Mailing Address - Phone:508-545-1178
Mailing Address - Fax:508-545-2798
Practice Address - Street 1:20 N MAIN ST
Practice Address - Street 2:STE255
Practice Address - City:SHERBORN
Practice Address - State:MA
Practice Address - Zip Code:01770-1500
Practice Address - Country:US
Practice Address - Phone:508-545-1178
Practice Address - Fax:508-545-2798
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3765103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03747Medicare PIN