Provider Demographics
NPI:1619023926
Name:BLACKBURN, MARTHA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANN
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 1:301 S FAIR OAKS AVE
Mailing Address - Street 2:406C
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2561
Mailing Address - Country:US
Mailing Address - Phone:626-449-8858
Mailing Address - Fax:626-449-8858
Practice Address - Street 1:301 S FAIR OAKS AVE
Practice Address - Street 2:406C
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2561
Practice Address - Country:US
Practice Address - Phone:626-449-8858
Practice Address - Fax:626-449-8858
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 5099101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health