Provider Demographics
NPI:1952432510
Name:BLACKSTEN, BRIAN (LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:BLACKSTEN
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 VERA CT
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-3732
Mailing Address - Country:US
Mailing Address - Phone:336-454-6729
Mailing Address - Fax:
Practice Address - Street 1:611 N LINDSAY ST
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4300
Practice Address - Country:US
Practice Address - Phone:336-802-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC04132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer