Provider Demographics
NPI:1053856070
Name:BLACKLEDGE, MICHAEL DAVID (DPT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:BLACKLEDGE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15811 AMBAUM BLVD SW STE 140
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-3066
Mailing Address - Country:US
Mailing Address - Phone:206-327-9880
Mailing Address - Fax:
Practice Address - Street 1:15811 AMBAUM BLVD SW STE 140
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166
Practice Address - Country:US
Practice Address - Phone:206-327-9880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-29
Last Update Date:2019-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT291773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist