Provider Demographics
NPI:1568522282
Name:BLACKBURN, STEPHANIE M (MED LMHC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MED LMHC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45 EASTMAN STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375
Mailing Address - Country:US
Mailing Address - Phone:508-238-5766
Mailing Address - Fax:508-238-8045
Practice Address - Street 1:45 EASTMAN STREET
Practice Address - Street 2:
Practice Address - City:SOUTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02375
Practice Address - Country:US
Practice Address - Phone:508-238-5766
Practice Address - Fax:508-238-8045
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5679103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist