Provider Demographics
NPI:1235651134
Name:BLACKWELL, MARISA SUE (PT)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:SUE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 420
Mailing Address - Street 2:
Mailing Address - City:REDFIELD
Mailing Address - State:SD
Mailing Address - Zip Code:57469-0420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:REDFIELD
Practice Address - State:SD
Practice Address - Zip Code:57469-1519
Practice Address - Country:US
Practice Address - Phone:605-472-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist