Provider Demographics
NPI:1548413057
Name:BLACKWOOD, HEATHER DAWN (DPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DAWN
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 SOLOMON AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3761
Mailing Address - Country:US
Mailing Address - Phone:518-280-4758
Mailing Address - Fax:
Practice Address - Street 1:435 4TH ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-5324
Practice Address - Country:US
Practice Address - Phone:518-271-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028593-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist