Provider Demographics
NPI:1053656959
Name:WILHELM, BLAKIE LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BLAKIE
Middle Name:LYNN
Last Name:WILHELM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:D611 STATE ROUTE 108
Mailing Address - Street 2:
Mailing Address - City:HOLGATE
Mailing Address - State:OH
Mailing Address - Zip Code:43527-9707
Mailing Address - Country:US
Mailing Address - Phone:419-264-5765
Mailing Address - Fax:
Practice Address - Street 1:395 HARDING ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-1315
Practice Address - Country:US
Practice Address - Phone:419-785-3302
Practice Address - Fax:419-784-9190
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA-5782225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant