Provider Demographics
NPI:1184218422
Name:BLACKMON, KAYLA (OT)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:MEADOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2603
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9379 FORESTWOOD LN
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4760
Practice Address - Country:US
Practice Address - Phone:571-208-1298
Practice Address - Fax:571-292-1757
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121283225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist