Provider Demographics
NPI:1730315995
Name:BLATNICK, CARMEN ELYSE (DPT)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:ELYSE
Last Name:BLATNICK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 S COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1430
Mailing Address - Country:US
Mailing Address - Phone:517-575-5493
Mailing Address - Fax:405-212-5175
Practice Address - Street 1:1005 S COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1430
Practice Address - Country:US
Practice Address - Phone:517-575-5493
Practice Address - Fax:405-212-5175
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-02
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZE0600X
TX1186757225100000X
TX246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX296685501Medicaid