Provider Demographics
NPI:1760478762
Name:BLICKENSTAFF, ROBERT CORY (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CORY
Last Name:BLICKENSTAFF
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13023 NE HIGHWAY 99
Mailing Address - Street 2:SUITE 7 PMB 109
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-2767
Mailing Address - Country:US
Mailing Address - Phone:360-600-2272
Mailing Address - Fax:877-362-9612
Practice Address - Street 1:717 NE 61ST ST
Practice Address - Street 2:SUITE 203
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8753
Practice Address - Country:US
Practice Address - Phone:360-600-2272
Practice Address - Fax:877-362-9612
Is Sole Proprietor?:No
Enumeration Date:2005-09-25
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009330225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA179487OtherLABOR & IND.
OR232559Medicaid
WA8382467Medicaid
OR232559Medicaid
WA179487OtherLABOR & IND.