Provider Demographics
NPI:1710201900
Name:BLACKBURN, KENDI
Entity Type:Individual
Prefix:
First Name:KENDI
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 1:1104 LYNNWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2910
Mailing Address - Country:US
Mailing Address - Phone:580-931-7708
Mailing Address - Fax:
Practice Address - Street 1:134 N 12TH AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4718
Practice Address - Country:US
Practice Address - Phone:580-924-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor