Healthcare Provider Details

I. General information

NPI: 1043800725
Provider Name (Legal Business Name): YVONNE LESLIE BLACKBURN CMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14572 US HIGHWAY 23
WAVERLY OH
45690-9373
US

IV. Provider business mailing address

2755 GIEKE RIDGE RD
OAK HILL OH
45656-9077
US

V. Phone/Fax

Practice location:
  • Phone: 740-947-6727
  • Fax:
Mailing address:
  • Phone: 740-688-8616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: