Provider Demographics
NPI:1619926623
Name:BLACKISTON, HEATHER MCCOY (DC)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MCCOY
Last Name:BLACKISTON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:E
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2316 PULASKI HWY STE B
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-3730
Mailing Address - Country:US
Mailing Address - Phone:410-642-9110
Mailing Address - Fax:410-642-9113
Practice Address - Street 1:2316 PULASKI HWY STE B
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-3730
Practice Address - Country:US
Practice Address - Phone:410-642-9110
Practice Address - Fax:410-642-9113
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02079111N00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2912304OtherAETNA INS
61670301OtherCAREFIRST BC
U90460Medicare UPIN
484F352MMedicare ID - Type Unspecified