Provider Demographics
NPI:1467878231
Name:BLIZZARD, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:BLIZZARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-2606
Mailing Address - Country:US
Mailing Address - Phone:321-704-9573
Mailing Address - Fax:
Practice Address - Street 1:106 E CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920-2606
Practice Address - Country:US
Practice Address - Phone:321-704-9573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA13312224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant