Provider Demographics
NPI:1932367455
Name:BLACKBURN, NICKE THERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:NICKE
Middle Name:THERESA
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:NICHOLSON
Other - Last Name:BLACKBURN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5429 ASHBY ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-1721
Mailing Address - Country:US
Mailing Address - Phone:713-529-2405
Mailing Address - Fax:
Practice Address - Street 1:5429 ASHBY ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-1721
Practice Address - Country:US
Practice Address - Phone:713-529-2405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD69532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry