Provider Demographics
NPI:1235611732
Name:BLAIR, CAROLYNN K (PTA)
Entity Type:Individual
Prefix:MS
First Name:CAROLYNN
Middle Name:K
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 COUNTY ROAD 45440
Mailing Address - Street 2:
Mailing Address - City:BLOSSOM
Mailing Address - State:TX
Mailing Address - Zip Code:75416-3323
Mailing Address - Country:US
Mailing Address - Phone:806-548-0875
Mailing Address - Fax:
Practice Address - Street 1:369 COUNTY ROAD 45440
Practice Address - Street 2:
Practice Address - City:BLOSSOM
Practice Address - State:TX
Practice Address - Zip Code:75416-3323
Practice Address - Country:US
Practice Address - Phone:806-548-0875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2009114225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant