Provider Demographics
NPI:1790991073
Name:BLACKBOURN, ERICA MARIE (MS, LLP, BCBA)
Entity Type:Individual
Prefix:MS
First Name:ERICA
Middle Name:MARIE
Last Name:BLACKBOURN
Suffix:
Gender:F
Credentials:MS, LLP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1864 GENOA CIR
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-9218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:138 W HIGHLAND RD
Practice Address - Street 2:SUITE 500-600
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-2168
Practice Address - Country:US
Practice Address - Phone:517-376-4831
Practice Address - Fax:517-376-4833
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012909103T00000X
1-15-19086103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist