Provider Demographics
NPI:1821509878
Name:BLACKBURN, ERIN LOUISE
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:LOUISE
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 1:313 PROSPECT AVE NE APT A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3596
Mailing Address - Country:US
Mailing Address - Phone:616-724-5225
Mailing Address - Fax:
Practice Address - Street 1:5366 EASTERN AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-6018
Practice Address - Country:US
Practice Address - Phone:616-608-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician