Provider Demographics
NPI:1245830926
Name:BLACKBURN, RACHEL (QTT)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:QTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 W SOUTH PARK AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-6533
Mailing Address - Country:US
Mailing Address - Phone:920-279-0635
Mailing Address - Fax:
Practice Address - Street 1:1370 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4636
Practice Address - Country:US
Practice Address - Phone:920-268-6940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4798-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor