Provider Demographics
NPI:1710265111
Name:BLACKBURN, RONDI A (OCCUPATIONAL THERAPI)
Entity Type:Individual
Prefix:
First Name:RONDI
Middle Name:A
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:OCCUPATIONAL THERAPI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5199
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-5199
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:612 S IRENE ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6629
Practice Address - Country:US
Practice Address - Phone:325-658-6571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10983324225X00000X
225X00000X
TX225X00000X
TX109042225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1396867966Medicaid