Provider Demographics
NPI:1134293400
Name:BLACKBURN, RICHARD ANTHONY (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ANTHONY
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-1275
Mailing Address - Country:US
Mailing Address - Phone:763-325-0300
Mailing Address - Fax:
Practice Address - Street 1:817 MAIN ST N
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1275
Practice Address - Country:US
Practice Address - Phone:763-325-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4743103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical