Provider Demographics
NPI:1205198249
Name:BLACKBURN, VINT
Entity Type:Individual
Prefix:
First Name:VINT
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:MILLVALE
Mailing Address - State:PA
Mailing Address - Zip Code:15209-2524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:132 HOWARD ST
Practice Address - Street 2:
Practice Address - City:MILLVALE
Practice Address - State:PA
Practice Address - Zip Code:15209-2524
Practice Address - Country:US
Practice Address - Phone:412-533-3995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4543992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry