Provider Demographics
NPI:1063660413
Name:BLADOS, MARY C
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:BLADOS
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 1:2097 TUNDRA CIR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-4040
Mailing Address - Country:US
Mailing Address - Phone:440-610-4802
Mailing Address - Fax:
Practice Address - Street 1:395 S PRATT PKWY
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6499
Practice Address - Country:US
Practice Address - Phone:440-610-4802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH012481225100000X
CO012481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist