MEDICARE: DR. ESME JANE BLACKBURN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	7797	MA

General Provider Information

NPI Number	:	1427041144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ESME JANE BLACKBURN PH.D.

Provider Business Mailing Address
First Line	:	22 MILL ST
Second Line	:	SUITE 407
City	:	ARLINGTON
State	:	MA
Zip	:	02476-4784
Country	:	US
Telephone Number	:	617-774-1085
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 MILL ST
Second Line	:	SUITE 407
City	:	ARLINGTON
State	:	MA
Zip	:	02476-4784
Country	:	US
Telephone Number	:	617-774-1085
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2005
Last Update Date	:	07/08/2007

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