Healthcare Provider Details

I. General information

NPI: 1619994670
Provider Name (Legal Business Name): LYNN A. BLACKBURN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNN A. BENNETT

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

10000 W INNOVATION DR
MILWAUKEE WI
53226-4837
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-3666
  • Fax:
Mailing address:
  • Phone: 414-456-5006
  • Fax: 414-456-6259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPYR0372
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2664
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: