Provider Demographics
NPI:1033903091
Name:BLACKBURN, MATTHEW SR
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BLACKBURN
Suffix:SR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 BUCKINGHAM GRV
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-6237
Mailing Address - Country:US
Mailing Address - Phone:330-573-3319
Mailing Address - Fax:
Practice Address - Street 1:422 BUCKINGHAM GRV
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-6237
Practice Address - Country:US
Practice Address - Phone:330-573-3319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT012226225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist