Provider Demographics
NPI:1477698538
Name:BLACKBURN, PATRICIA (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4003
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0020
Mailing Address - Country:US
Mailing Address - Phone:704-865-3525
Mailing Address - Fax:704-865-3520
Practice Address - Street 1:1425 MCFARLAND AVE
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741-2215
Practice Address - Country:US
Practice Address - Phone:484-754-7273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0062881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106587Medicaid
NC144VHOtherBCBS
195922OtherMEDCOST
NC144VHOtherBCBS