Provider Demographics
NPI:1437790342
Name:BLACKBURN, LE'NIA NOEL
Entity type:Individual
Prefix:
First Name:LE'NIA
Middle Name:NOEL
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 S AUBURN ST STE C
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-4318
Mailing Address - Country:US
Mailing Address - Phone:916-787-8860
Mailing Address - Fax:
Practice Address - Street 1:500 CROWN POINT CIR STE 120
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9561
Practice Address - Country:US
Practice Address - Phone:530-265-5811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2025-04-20
Deactivation Date:2023-10-27
Deactivation Code:
Reactivation Date:2024-02-13
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X, 171M00000X
172V00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171RMedicaid