Provider Demographics
NPI:1134475080
Name:BLONKVIST, KATHRYN G (PT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:G
Last Name:BLONKVIST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATY
Other - Middle Name:G
Other - Last Name:GRESHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:301 DODSON ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-6334
Mailing Address - Country:US
Mailing Address - Phone:432-687-0235
Mailing Address - Fax:432-570-8713
Practice Address - Street 1:301 DODSON ST.
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701
Practice Address - Country:US
Practice Address - Phone:432-687-0235
Practice Address - Fax:432-570-8713
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1194900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist