Provider Demographics
NPI:1235255738
Name:DEBORD, KENNETH BLAKE (PTA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:BLAKE
Last Name:DEBORD
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 1:1921 NEW GARDEN RD
Mailing Address - Street 2:APT J305
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-2193
Mailing Address - Country:US
Mailing Address - Phone:336-880-1295
Mailing Address - Fax:
Practice Address - Street 1:618 S MAIN ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5020
Practice Address - Country:US
Practice Address - Phone:336-951-4557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2226225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant