Provider Demographics
NPI:1841368511
Name:BLACKMORE, SUSAN M (OT)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:BLACKMORE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S HENDERSON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3530
Mailing Address - Country:US
Mailing Address - Phone:610-768-5940
Mailing Address - Fax:610-768-5947
Practice Address - Street 1:700 S HENDERSON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-3530
Practice Address - Country:US
Practice Address - Phone:610-768-5940
Practice Address - Fax:610-768-5947
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC001407L225XH1200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1452890OtherIBC - PERSONAL CHOICE
PA2138759000OtherIBC - KEYSTONE