Provider Demographics
NPI:1972917367
Name:BLACKLEDGE, SARAH ELISE (DPT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ELISE
Last Name:BLACKLEDGE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:ELISE
Other - Last Name:HOLIFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-583-9464
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:206 OLD CORINTH RD
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2932
Practice Address - Country:US
Practice Address - Phone:601-583-9464
Practice Address - Fax:601-583-9465
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05538733Medicaid
MS381290YKFFMedicare PIN