Healthcare Provider Details

I. General information

NPI: 1841211026
Provider Name (Legal Business Name): TEGAN BLACKBIRD PH D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S MAIN ST
MANHEIM PA
17545-1602
US

IV. Provider business mailing address

40 PHEASANT CT
ELIZABETHTOWN PA
17022-9206
US

V. Phone/Fax

Practice location:
  • Phone: 717-964-8897
  • Fax:
Mailing address:
  • Phone: 717-964-8897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS004895L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS004895L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: