Provider Demographics
NPI:1053142679
Name:BLACKWELL, BLYTHE W (PT, DPT)
Entity type:Individual
Prefix:
First Name:BLYTHE
Middle Name:W
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 GRAND AVE APT 6305
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-6189
Mailing Address - Country:US
Mailing Address - Phone:769-232-5205
Mailing Address - Fax:
Practice Address - Street 1:14280 WALSINGHAM RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-3231
Practice Address - Country:US
Practice Address - Phone:727-596-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL41932225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist