Basic Information
| Provider Information | |||||||||
| NPI: | 1891208393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | BRYSON | ||||||||
| MiddleName: | DALE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 8TH AVE W STE 101 | ||||||||
| Address2: | |||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342214737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417764000 | ||||||||
| FaxNumber: | 9418454963 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 N 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342668752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634941242 | ||||||||
| FaxNumber: | 8634910466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2017 | ||||||||
| LastUpdateDate: | 11/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW14904 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.