Provider Demographics
NPI:1629693601
Name:BASS, BLAKELYNN COLCLASURE (DPT)
Entity Type:Individual
Prefix:
First Name:BLAKELYNN
Middle Name:COLCLASURE
Last Name:BASS
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 1:4616 HIGHWAY 84 W
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3357
Mailing Address - Country:US
Mailing Address - Phone:318-336-5400
Mailing Address - Fax:318-336-8622
Practice Address - Street 1:4616 HIGHWAY 84 W
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3357
Practice Address - Country:US
Practice Address - Phone:318-336-5400
Practice Address - Fax:318-336-8622
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10613261QP2000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2532499Medicaid