Provider Demographics
NPI:1801376827
Name:BLACKBURN, WESLEY SHANE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:SHANE
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HANCOCK STREET
Mailing Address - Street 2:APARTMENT 322
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:15427
Mailing Address - Country:US
Mailing Address - Phone:724-288-8779
Mailing Address - Fax:724-288-8779
Practice Address - Street 1:150 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-2914
Practice Address - Country:US
Practice Address - Phone:781-449-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76489235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist