Healthcare Provider Details

I. General information

NPI: 1902966104
Provider Name (Legal Business Name): ELIZABETH RUTH BLOM MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH EILERTSON

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4284 TRAIL BOSS DR STE 130
CASTLE ROCK CO
80104-7521
US

IV. Provider business mailing address

4284 TRAIL BOSS DR STE 130
CASTLE ROCK CO
80104-7521
US

V. Phone/Fax

Practice location:
  • Phone: 303-663-8086
  • Fax: 303-663-8289
Mailing address:
  • Phone: 303-663-8086
  • Fax: 303-663-8289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7150
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1157200
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: