Provider Demographics
NPI:1760746648
Name:BLACKWOOD, TRINA NICOLE (MOTR/L)
Entity Type:Individual
Prefix:MRS
First Name:TRINA
Middle Name:NICOLE
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CHAPEL GROVE CT
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4339
Mailing Address - Country:US
Mailing Address - Phone:636-443-5379
Mailing Address - Fax:
Practice Address - Street 1:101 CHAPEL GROVE CT
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-4339
Practice Address - Country:US
Practice Address - Phone:636-443-5379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011022964225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics