Provider Demographics
NPI:1053629030
Name:BLADSTROM, EVALYN NELSON
Entity Type:Individual
Prefix:MS
First Name:EVALYN
Middle Name:NELSON
Last Name:BLADSTROM
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 1:3 EAST 85TH STREET
Mailing Address - Street 2:APT 6B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028
Mailing Address - Country:US
Mailing Address - Phone:917-526-2343
Mailing Address - Fax:
Practice Address - Street 1:65 COURT ST
Practice Address - Street 2:ROOM 1503
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4916
Practice Address - Country:US
Practice Address - Phone:718-935-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013422225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist