Provider Demographics
NPI:1609260231
Name:BLALOCK, TRICIA DENISE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:DENISE
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 STONE CREEK RANCH RD
Mailing Address - Street 2:
Mailing Address - City:MC GREGOR
Mailing Address - State:TX
Mailing Address - Zip Code:76657-3771
Mailing Address - Country:US
Mailing Address - Phone:903-573-4814
Mailing Address - Fax:
Practice Address - Street 1:2001 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-2338
Practice Address - Country:US
Practice Address - Phone:903-434-8011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1098242225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist