Provider Demographics
NPI:1760655179
Name:BLACKWOOD-WIDNER, ANN E (PT)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:E
Last Name:BLACKWOOD-WIDNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:E
Other - Last Name:BLACKWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2725 WATER RIDGE PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-4580
Mailing Address - Country:US
Mailing Address - Phone:704-831-5065
Mailing Address - Fax:704-831-5066
Practice Address - Street 1:11440 PARKSIDE DR
Practice Address - Street 2:SUITE 301
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2658
Practice Address - Country:US
Practice Address - Phone:865-777-3748
Practice Address - Fax:865-777-3827
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305205029OtherVIRGINIA LICENSE
FL15751OtherFLORIDA LICENSE
TN6135OtherTN LICENSE