Provider Demographics
NPI:1639499437
Name:BLACKBURN, KRISTIN R (MSW, LMSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:R
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 PAULINE BLVD
Mailing Address - Street 2:STE. 10
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5047
Mailing Address - Country:US
Mailing Address - Phone:734-994-1531
Mailing Address - Fax:
Practice Address - Street 1:1945 PAULINE BLVD
Practice Address - Street 2:STE. 10
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-5047
Practice Address - Country:US
Practice Address - Phone:734-994-1531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010678351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical