Provider Demographics
NPI:1811452592
Name:SIMS, BLAINE A (PTA)
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:A
Last Name:SIMS
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 1:10318 SOLDIER TRL
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051-7866
Mailing Address - Country:US
Mailing Address - Phone:859-750-8695
Mailing Address - Fax:
Practice Address - Street 1:HWY 127 N, OWENTON
Practice Address - Street 2:
Practice Address - City:OWEN
Practice Address - State:KY
Practice Address - Zip Code:40359
Practice Address - Country:US
Practice Address - Phone:502-484-5721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA03897225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant