Provider Demographics
NPI:1134661721
Name:BLACKSTONE, ERIC (DPT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:BLACKSTONE
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 1:12544 DILLINGHAM SQ
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5259
Mailing Address - Country:US
Mailing Address - Phone:703-730-6969
Mailing Address - Fax:
Practice Address - Street 1:12544 DILLINGHAM SQ
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5259
Practice Address - Country:US
Practice Address - Phone:703-730-6969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210784225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305210784OtherLICENSE NUMBER