Provider Demographics
NPI:1205057296
Name:BLACKBURN, MICHAEL HOWARD (ATC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:HOWARD
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 SPORTS DR
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2741
Mailing Address - Country:US
Mailing Address - Phone:231-591-2872
Mailing Address - Fax:
Practice Address - Street 1:210 SPORTS DR
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2741
Practice Address - Country:US
Practice Address - Phone:231-591-2872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer