Provider Demographics
NPI:1184754475
Name:BLACKARD, DOUGLAS OLIVER (MS, MHA, LAT, CMPE)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:OLIVER
Last Name:BLACKARD
Suffix:
Gender:M
Credentials:MS, MHA, LAT, CMPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3618 GARRETTSVILLE DR
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-4984
Mailing Address - Country:US
Mailing Address - Phone:281-412-2769
Mailing Address - Fax:
Practice Address - Street 1:3618 GARRETTSVILLE DR
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-4984
Practice Address - Country:US
Practice Address - Phone:281-412-2769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
129039099OtherNATA CERTIFICATION