Provider Demographics
NPI:1831367671
Name:FUKUNAGA-BLOCK, BLYTHE (PT)
Entity type:Individual
Prefix:
First Name:BLYTHE
Middle Name:
Last Name:FUKUNAGA-BLOCK
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 1:15344 KARL AVE
Mailing Address - Street 2:
Mailing Address - City:MONTE SERENO
Mailing Address - State:CA
Mailing Address - Zip Code:95030-2230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15344 KARL AVE
Practice Address - Street 2:
Practice Address - City:MONTE SERENO
Practice Address - State:CA
Practice Address - Zip Code:95030-2230
Practice Address - Country:US
Practice Address - Phone:408-395-5809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT7891225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist