Basic Information
| Provider Information | |||||||||
| NPI: | 1801376827 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | SHANE | ||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 HANCOCK STREET | ||||||||
| Address2: | APARTMENT 322 | ||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 15427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242888779 | ||||||||
| FaxNumber: | 7242888779 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | NEEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024922914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814494040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2018 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 76489 | MA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.