Provider Demographics
NPI:1720283328
Name:BLACKETT, STEPHEN JOHN (PTA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:JOHN
Last Name:BLACKETT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:486 TOWN FARM RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:VT
Mailing Address - Zip Code:05733-9098
Mailing Address - Country:US
Mailing Address - Phone:802-247-6340
Mailing Address - Fax:
Practice Address - Street 1:46 NICHOLS ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-3275
Practice Address - Country:US
Practice Address - Phone:802-775-2941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT041-00004013140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric