Provider Demographics
NPI:1063805380
Name:BLACKBURN, HOLEN
Entity type:Individual
Prefix:
First Name:HOLEN
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SAGAMORE PKWY N
Mailing Address - Street 2:#207
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2461
Mailing Address - Country:US
Mailing Address - Phone:765-446-0006
Mailing Address - Fax:
Practice Address - Street 1:1000 SAGAMORE PKWY N
Practice Address - Street 2:#207
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2461
Practice Address - Country:US
Practice Address - Phone:765-446-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002659A101YM0800X, 101YM0800X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health