Provider Demographics
NPI:1689208282
Name:BLOCKER, CONNIE CHEN (PT)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:CHEN
Last Name:BLOCKER
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:CHEN
Other - Last Name:BENTIVOLIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-1669
Mailing Address - Country:US
Mailing Address - Phone:630-881-7866
Mailing Address - Fax:
Practice Address - Street 1:130 CRISANTO AVE STE A
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-6272
Practice Address - Country:US
Practice Address - Phone:803-746-4655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16843225100000X
SC12523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist