Provider Demographics
NPI:1538127345
Name:BLACKBURN, LISA D (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 KINGS HWY N
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1912
Mailing Address - Country:US
Mailing Address - Phone:856-428-1477
Mailing Address - Fax:
Practice Address - Street 1:1101 KINGS HWY N
Practice Address - Street 2:SUITE 208
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1912
Practice Address - Country:US
Practice Address - Phone:856-428-1477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA082698002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry