Provider Demographics
NPI:1649512484
Name:BLACKBURN, SUSAN DIANE (LMSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:DIANE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:DIANE
Other - Last Name:GASPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 776974
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6974
Mailing Address - Country:US
Mailing Address - Phone:231-672-2119
Mailing Address - Fax:313-432-7759
Practice Address - Street 1:2006 HOLTON RD
Practice Address - Street 2:
Practice Address - City:NORTH MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1505
Practice Address - Country:US
Practice Address - Phone:231-672-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010796041041C0700X, 101YA0400X
MI68010179604101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1649512484Medicaid