Provider Demographics
NPI:1649958661
Name:BLY, BETH (PTA)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:BLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1767 ZIEGLER AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE GRASS
Mailing Address - State:IA
Mailing Address - Zip Code:52726-9408
Mailing Address - Country:US
Mailing Address - Phone:563-570-3335
Mailing Address - Fax:
Practice Address - Street 1:2951 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-2784
Practice Address - Country:US
Practice Address - Phone:563-345-6317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA116223225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant