Provider Demographics
NPI:1275114977
Name:BLACKBURN, KEITH JEREMY
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JEREMY
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 1:171 GRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-3847
Mailing Address - Country:US
Mailing Address - Phone:978-632-4574
Mailing Address - Fax:
Practice Address - Street 1:171 GRAHAM ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-3847
Practice Address - Country:US
Practice Address - Phone:978-632-4574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)