Provider Demographics
NPI:1659762433
Name:BLACKBURN, BRANDI NICOLE (MOTR/L)
Entity Type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:NICOLE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5530 MILAN OAKVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160-9157
Mailing Address - Country:US
Mailing Address - Phone:734-752-7281
Mailing Address - Fax:
Practice Address - Street 1:5530 MILAN OAKVILLE RD
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-9157
Practice Address - Country:US
Practice Address - Phone:734-752-7281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-14
Last Update Date:2015-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006653225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist