Provider Demographics
NPI:1710716451
Name:BLACKBURN, JUSTIN LAWRENCE (CDCA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LAWRENCE
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6431 STATE ROUTE 104
Mailing Address - Street 2:
Mailing Address - City:MC DERMOTT
Mailing Address - State:OH
Mailing Address - Zip Code:45652-8943
Mailing Address - Country:US
Mailing Address - Phone:740-981-6987
Mailing Address - Fax:
Practice Address - Street 1:6431 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:MC DERMOTT
Practice Address - State:OH
Practice Address - Zip Code:45652-8943
Practice Address - Country:US
Practice Address - Phone:740-981-6987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.189376101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)