Provider Demographics
NPI:1265445431
Name:BLACKBURN, DEBORAH WEBB (PHD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:WEBB
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9376 ATLEE STATION RD
Mailing Address - Street 2:HANOVER FAMILY PHYSICIANS PC
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116
Mailing Address - Country:US
Mailing Address - Phone:804-730-0990
Mailing Address - Fax:804-730-8752
Practice Address - Street 1:9376 ATLEE STATION RD
Practice Address - Street 2:HANOVER FAMILY PHYSICIANS PC
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116
Practice Address - Country:US
Practice Address - Phone:804-730-0990
Practice Address - Fax:804-730-8752
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001741103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA07710283Medicaid
VAR61276Medicare UPIN