Provider Demographics
NPI:1801143094
Name:BOLLWITT, BLAKE EVAN (DPT)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:EVAN
Last Name:BOLLWITT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 N 8TH AVE
Mailing Address - Street 2:P.O. BOX 846
Mailing Address - City:BURWELL
Mailing Address - State:NE
Mailing Address - Zip Code:68823-4168
Mailing Address - Country:US
Mailing Address - Phone:402-340-4167
Mailing Address - Fax:308-346-5111
Practice Address - Street 1:2305 N ST
Practice Address - Street 2:
Practice Address - City:ORD
Practice Address - State:NE
Practice Address - Zip Code:68862-1632
Practice Address - Country:US
Practice Address - Phone:402-340-4167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist