Provider Demographics
NPI:1801971114
Name:BLACKBURN, BRUCE M (MPT, CWS)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:M
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MPT, CWS
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:818 HIGH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-1152
Mailing Address - Country:US
Mailing Address - Phone:410-778-6565
Mailing Address - Fax:410-778-6536
Practice Address - Street 1:818 HIGH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1152
Practice Address - Country:US
Practice Address - Phone:410-778-6565
Practice Address - Fax:410-778-6536
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405156400Medicaid
MD405156400Medicaid