Provider Demographics
NPI:1457761074
Name:BLASINGAME, MISTY (PT)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:BLASINGAME
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 N COIT RD
Mailing Address - Street 2:2035 PROMENADE CENTER
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-5446
Mailing Address - Country:US
Mailing Address - Phone:972-437-2048
Mailing Address - Fax:972-480-8514
Practice Address - Street 1:510 N COIT RD
Practice Address - Street 2:2035 PROMENADE CENTER
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-5446
Practice Address - Country:US
Practice Address - Phone:972-437-2048
Practice Address - Fax:972-480-8514
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1183820225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist