MEDICARE: DR. NICKE THERESA BLACKBURN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	D6953	TX

General Provider Information

NPI Number	:	1932367455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICKE THERESA BLACKBURN M.D.

Provider Business Mailing Address
First Line	:	5429 ASHBY ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-1721
Country	:	US
Telephone Number	:	713-529-2405
Fax Number	:

Provider Business Practice Location Address
First Line	:	5429 ASHBY ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-1721
Country	:	US
Telephone Number	:	713-529-2405
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	05/30/2008

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