Provider Demographics
NPI:1013715150
Name:BLACKBURN, TIMOTHY ALAN
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALAN
Last Name:BLACKBURN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 BANDANA BLVD W
Mailing Address - Street 2:STE 210
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 NICKERSON ST STE 300
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-1699
Practice Address - Country:US
Practice Address - Phone:888-364-5977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61574268101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health