Provider Demographics
NPI:1932332541
Name:BLAYLOCK, MOLLY JEAN (LMP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:JEAN
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12615 E MISSION AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-3060
Mailing Address - Country:US
Mailing Address - Phone:509-891-2368
Mailing Address - Fax:
Practice Address - Street 1:12615 E MISSION AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-3060
Practice Address - Country:US
Practice Address - Phone:509-891-2368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-29
Last Update Date:2009-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60032132225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist