Provider Demographics
NPI:1417152893
Name:BLALOCK, VICKIE JOHNSON (PT)
Entity Type:Individual
Prefix:MRS
First Name:VICKIE
Middle Name:JOHNSON
Last Name:BLALOCK
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 1:6408 BEACON POINTE CIR
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3199
Mailing Address - Country:US
Mailing Address - Phone:423-843-0905
Mailing Address - Fax:
Practice Address - Street 1:1 SISKIN PLZ
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-1306
Practice Address - Country:US
Practice Address - Phone:423-634-1389
Practice Address - Fax:423-634-1594
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000002079225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist