Provider Demographics
NPI:1689199671
Name:BLALOCK, AUSTIN (PT)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18301 N 79TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8463
Mailing Address - Country:US
Mailing Address - Phone:623-486-3333
Mailing Address - Fax:623-486-3355
Practice Address - Street 1:18301 N 79TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8463
Practice Address - Country:US
Practice Address - Phone:623-486-3333
Practice Address - Fax:623-486-3333
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13214225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist