Provider Demographics
NPI:1114409588
Name:BLACKMON, BRENTLEY KYLE (PTA)
Entity Type:Individual
Prefix:
First Name:BRENTLEY
Middle Name:KYLE
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 OWEN LN
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5599
Mailing Address - Country:US
Mailing Address - Phone:254-772-8900
Mailing Address - Fax:
Practice Address - Street 1:401 OWEN LN
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5599
Practice Address - Country:US
Practice Address - Phone:254-772-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-03
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2108097225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant