Provider Demographics
NPI:1649721580
Name:BLACKBURN, DOUGLAS JOHN (ATC)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JOHN
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 1:12410 E SINTO AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-2280
Mailing Address - Country:US
Mailing Address - Phone:509-242-3944
Mailing Address - Fax:
Practice Address - Street 1:12410 E SINTO AVE STE 205
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2280
Practice Address - Country:US
Practice Address - Phone:509-242-3944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-15
Last Update Date:2016-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1 605743102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer