Provider Demographics
NPI:1902209349
Name:BLACKBURN, DASHA LEIGH (LMT)
Entity Type:Individual
Prefix:
First Name:DASHA
Middle Name:LEIGH
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4138 S HARVARD AVE STE C3
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2653
Mailing Address - Country:US
Mailing Address - Phone:918-828-2899
Mailing Address - Fax:
Practice Address - Street 1:4138 S HARVARD AVE STE C3
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2653
Practice Address - Country:US
Practice Address - Phone:918-828-2899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1030891225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist