Provider Demographics
NPI:1588043418
Name:BLACKBURN, DORIS
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:
Last Name:BLACKBURN
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 1:1280 TERMINAL WAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-3219
Mailing Address - Country:US
Mailing Address - Phone:775-337-9359
Mailing Address - Fax:
Practice Address - Street 1:1280 TERMINAL WAY
Practice Address - Street 2:SUITE 3
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-3219
Practice Address - Country:US
Practice Address - Phone:775-337-9359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1336423433Medicaid