Provider Demographics
NPI:1598455032
Name:BLAIR, KELLY (CMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BARROWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5714 LONETREE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-3734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5714 LONETREE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-3734
Practice Address - Country:US
Practice Address - Phone:916-259-2510
Practice Address - Fax:916-259-0073
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87680225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist