Provider Demographics
NPI:1255818035
Name:BLAUVELT, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BLAUVELT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 KETTLE CREEK RD APT 7
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-1971
Mailing Address - Country:US
Mailing Address - Phone:732-598-4831
Mailing Address - Fax:
Practice Address - Street 1:2 KATHLEEN DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-2269
Practice Address - Country:US
Practice Address - Phone:732-474-6055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00295700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant