Provider Demographics
NPI:1013664655
Name:BLAZ, KARLIE ANNE
Entity Type:Individual
Prefix:
First Name:KARLIE
Middle Name:ANNE
Last Name:BLAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:TX
Mailing Address - Zip Code:79772-7338
Mailing Address - Country:US
Mailing Address - Phone:815-354-4819
Mailing Address - Fax:
Practice Address - Street 1:2323 TEXAS ST
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:TX
Practice Address - Zip Code:79772-7338
Practice Address - Country:US
Practice Address - Phone:432-447-3551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160009515225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant