Provider Demographics
NPI:1740752591
Name:SALAMON, KATHLEEN BLACKMAN
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:BLACKMAN
Last Name:SALAMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844 ALLSTON WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5202
Mailing Address - Country:US
Mailing Address - Phone:209-639-0997
Mailing Address - Fax:
Practice Address - Street 1:582 EAST HARDING AVENUE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6110
Practice Address - Country:US
Practice Address - Phone:209-279-5617
Practice Address - Fax:209-718-7190
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT57062251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT5706OtherCALIFORNIA BOARD OF PHYSICAL THERAPY