Provider Demographics
NPI:1437573342
Name:BLACKADAR OLDHAM, KATHRYN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:BLACKADAR OLDHAM
Suffix:
Gender:F
Credentials:PT, DPT
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 1107
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-1107
Mailing Address - Country:US
Mailing Address - Phone:208-756-2005
Mailing Address - Fax:208-756-4020
Practice Address - Street 1:802 SHOUP ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4305
Practice Address - Country:US
Practice Address - Phone:208-756-2005
Practice Address - Fax:208-756-4020
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20005459OtherMEDICARE PTAN