Provider Demographics
NPI:1689679466
Name:BLACKERBY, GINA LYNETTE (PT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:LYNETTE
Last Name:BLACKERBY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 BRIDWELL RD
Mailing Address - Street 2:
Mailing Address - City:IOWA PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76367-8104
Mailing Address - Country:US
Mailing Address - Phone:940-855-8019
Mailing Address - Fax:
Practice Address - Street 1:620 W BANK ST
Practice Address - Street 2:
Practice Address - City:IOWA PARK
Practice Address - State:TX
Practice Address - Zip Code:76367-2830
Practice Address - Country:US
Practice Address - Phone:940-592-5900
Practice Address - Fax:940-592-5969
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1065332225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00516ZMedicare PIN