Healthcare Provider Details

I. General information

NPI: 1346325917
Provider Name (Legal Business Name): CAROLYN B BLACKBURN MHC, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349-A EAST AVENUE K-6
LANCASTER CA
93535
US

IV. Provider business mailing address

2323A E PALMDALE BLVD
PALMDALE CA
93550-4957
US

V. Phone/Fax

Practice location:
  • Phone: 661-723-4260
  • Fax: 661-945-2495
Mailing address:
  • Phone: 661-223-3838
  • Fax: 661-945-2495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN388421
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberRN388421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: