Healthcare Provider Details

I. General information

NPI: 1376628883
Provider Name (Legal Business Name): KAREN LYNN BLACKWELL PT, PCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAREN KLECKA BLACKWELL PT, PCS

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W NEW INDIAN TR AIL CT
AURORA IL
60506
US

IV. Provider business mailing address

1760 MARION CT
WHEATON IL
60187-3319
US

V. Phone/Fax

Practice location:
  • Phone: 630-966-4000
  • Fax: 630-906-9858
Mailing address:
  • Phone: 630-653-0659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: