Provider Demographics
NPI:1790748713
Name:BLACKBURN, KIMBERLY ANN (ATC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11694 PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44149-2928
Mailing Address - Country:US
Mailing Address - Phone:440-572-0126
Mailing Address - Fax:
Practice Address - Street 1:3301 N PARK BLVD
Practice Address - Street 2:BEAUMONT SCHOOL
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-4258
Practice Address - Country:US
Practice Address - Phone:440-223-3292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-0152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer