Provider Demographics
NPI:1245349273
Name:BLACKBURN, HEATHER (DSC, MS, PT, PCS)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:DSC, MS, PT, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:ST ALBANS BAY
Mailing Address - State:VT
Mailing Address - Zip Code:05481-0032
Mailing Address - Country:US
Mailing Address - Phone:802-309-9753
Mailing Address - Fax:
Practice Address - Street 1:913 WEST SHORE RD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS BAY
Practice Address - State:VT
Practice Address - Zip Code:05481
Practice Address - Country:US
Practice Address - Phone:802-309-9753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003132225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist