Provider Demographics
NPI:1285041590
Name:BLACKWELL, ERYN
Entity Type:Individual
Prefix:
First Name:ERYN
Middle Name:
Last Name:BLACKWELL
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 1:5710 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-5901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5710 BAKER RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-5901
Practice Address - Country:US
Practice Address - Phone:952-767-4201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9332235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist