=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841211026
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TEGAN BLACKBIRD PH D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2006
-----------------------------------------------------
Last Update Date | 08/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 S MAIN ST
-----------------------------------------------------
City | MANHEIM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17545-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-964-8897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 PHEASANT CT
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17022-9206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-964-8897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS004895L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PS004895L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------