Healthcare Provider Details

I. General information

NPI: 1417143298
Provider Name (Legal Business Name): AMY BLACKBURN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 OLD ROLLINSFORD RD STE 302
DOVER NH
03820-2819
US

IV. Provider business mailing address

789 CENTRAL AVE
DOVER NH
03820-2526
US

V. Phone/Fax

Practice location:
  • Phone: 603-742-9200
  • Fax: 603-742-4605
Mailing address:
  • Phone: 603-742-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1470
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number7407
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: