Provider Demographics
NPI:1649748302
Name:BLOXOM, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:BLOXOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 KELLY ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:75840-2016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 MOODY ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:TX
Practice Address - Zip Code:75840-3036
Practice Address - Country:US
Practice Address - Phone:903-390-8382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-10
Last Update Date:2018-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212939224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant