Healthcare Provider Details

I. General information

NPI: 1588152466
Provider Name (Legal Business Name): KAYLEA BLACKBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E DUBLIN GRANVILLE RD
WORTHINGTON OH
43085-3192
US

IV. Provider business mailing address

943 LEXDALE LN
MANSFIELD OH
44907-2611
US

V. Phone/Fax

Practice location:
  • Phone: 614-445-5301
  • Fax:
Mailing address:
  • Phone: 419-565-7339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: