Healthcare Provider Details

I. General information

NPI: 1437790342
Provider Name (Legal Business Name): LE'NIA NOEL BLACKBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 04/20/2025
Certification Date: 04/20/2025
Deactivation Date: 10/27/2023
Reactivation Date: 02/13/2024

III. Provider practice location address

500 CROWN POINT CIR STE 120
GRASS VALLEY CA
95945-9561
US

IV. Provider business mailing address

760 S AUBURN ST STE C
GRASS VALLEY CA
95945-4318
US

V. Phone/Fax

Practice location:
  • Phone: 530-265-5811
  • Fax:
Mailing address:
  • Phone: 916-787-8860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: