Provider Demographics
NPI:1922476274
Name:BLACKBURN, LAUREN TERRY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:TERRY
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 FAIRFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-6607
Mailing Address - Country:US
Mailing Address - Phone:910-550-3803
Mailing Address - Fax:910-550-3803
Practice Address - Street 1:218 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3204
Practice Address - Country:US
Practice Address - Phone:910-875-6042
Practice Address - Fax:910-875-6065
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0098081041C0700X
NCC0110191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1922476274Medicaid