Provider Demographics
NPI:1760451280
Name:BLUE, DAWANNA D (PT)
Entity Type:Individual
Prefix:MS
First Name:DAWANNA
Middle Name:D
Last Name:BLUE
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 1:129 AIRPARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350
Mailing Address - Country:US
Mailing Address - Phone:601-656-2525
Mailing Address - Fax:601-774-5125
Practice Address - Street 1:25117 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MS
Practice Address - Zip Code:39365-9088
Practice Address - Country:US
Practice Address - Phone:601-774-1588
Practice Address - Fax:601-774-5125
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3957225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
256557Medicare ID - Type Unspecified