Provider Demographics
NPI:1427266493
Name:BLACKBURN, TAMARA (COTA)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3489 NE CATAWBA RD
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-9122
Mailing Address - Country:US
Mailing Address - Phone:419-797-6328
Mailing Address - Fax:
Practice Address - Street 1:1325 HULL RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-6062
Practice Address - Country:US
Practice Address - Phone:419-626-4162
Practice Address - Fax:419-626-2071
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA01138224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant