Provider Demographics
NPI:1609437896
Name:BLACKBURN, COURTNEY (MA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 REAR W 4TH ST
Mailing Address - Street 2:APT 1
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701
Mailing Address - Country:US
Mailing Address - Phone:606-625-0353
Mailing Address - Fax:
Practice Address - Street 1:114 RENICK AVE
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2879
Practice Address - Country:US
Practice Address - Phone:740-851-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103T00000X
390200000X
WV1309103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program