Provider Demographics
NPI:1275176695
Name:BLACKETT, DEBRA L
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:BLACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 ALVESTON DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1802
Mailing Address - Country:US
Mailing Address - Phone:248-688-5752
Mailing Address - Fax:
Practice Address - Street 1:2620 ALVESTON DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-1802
Practice Address - Country:US
Practice Address - Phone:248-688-5752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator