Provider Demographics
NPI:1003614116
Name:ADERHOLD, BLAIR GUICE
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:GUICE
Last Name:ADERHOLD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6811 OLD FORT BAYOU RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-7988
Mailing Address - Country:US
Mailing Address - Phone:228-861-5397
Mailing Address - Fax:
Practice Address - Street 1:1530 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3601
Practice Address - Country:US
Practice Address - Phone:228-861-5397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT7286225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist