Provider Demographics
NPI:1518515410
Name:BLACKBURN, MARY CATHERINE (SLPA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 N DATE APT 2
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-2158
Mailing Address - Country:US
Mailing Address - Phone:928-386-4039
Mailing Address - Fax:
Practice Address - Street 1:9385 W DONALD DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2988
Practice Address - Country:US
Practice Address - Phone:602-910-1409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant