Provider Demographics
NPI:1689151284
Name:BLACKWELL, TORI BREANNE (MOT, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:TORI
Middle Name:BREANNE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:TORI
Other - Middle Name:BREANNE
Other - Last Name:RAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:3731-A 6TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-291-3515
Mailing Address - Fax:619-374-2552
Practice Address - Street 1:3731-A 6TH AVENUE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-291-3515
Practice Address - Fax:619-374-2552
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007091225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT007091OtherSTATE BOARD OF OCCUPATIONAL THERAPY