Provider Demographics
NPI:1568696763
Name:BLEVINS, NICOLE LEIGH (NCBTM)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LEIGH
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:NCBTM
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LEIGH
Other - Last Name:POFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NCBTM
Mailing Address - Street 1:365 BROADWAY ST # 2
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-1145
Mailing Address - Country:US
Mailing Address - Phone:270-422-3694
Mailing Address - Fax:270-422-3694
Practice Address - Street 1:365 BROADWAY ST # 2
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1145
Practice Address - Country:US
Practice Address - Phone:270-422-3694
Practice Address - Fax:270-422-3694
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2052225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist