Provider Demographics
NPI:1366106312
Name:BLACKBURN, JUSTIN C (LPC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:C
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25708-0390
Mailing Address - Country:US
Mailing Address - Phone:304-696-1636
Mailing Address - Fax:304-696-1623
Practice Address - Street 1:1520 SLATE CREEK RD STE 201
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6975
Practice Address - Country:US
Practice Address - Phone:276-242-2001
Practice Address - Fax:276-312-8337
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010929101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor