Provider Demographics
NPI:1568650299
Name:BLACKSTONE, MAURA K (DPT)
Entity Type:Individual
Prefix:
First Name:MAURA
Middle Name:K
Last Name:BLACKSTONE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MAURA
Other - Middle Name:
Other - Last Name:NUGENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:411 WALNUT ST # 15228
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-3443
Mailing Address - Country:US
Mailing Address - Phone:201-951-4890
Mailing Address - Fax:201-907-3165
Practice Address - Street 1:65 E WADSWORTH PARK DR STE 230
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8096
Practice Address - Country:US
Practice Address - Phone:385-308-8034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211239225100000X
NJ40QA01260100225100000X
DCPT210002312225100000X
CA304618225100000X
PAPT031329225100000X
IL070027460225100000X
TX1363068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist