Healthcare Provider Details

I. General information

NPI: 1316257637
Provider Name (Legal Business Name): KATE ERICA BLACKBURN PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 MEYER RD
WENTZVILLE MO
63385-3457
US

IV. Provider business mailing address

2315 HIGHWAY K
O FALLON MO
63368-8659
US

V. Phone/Fax

Practice location:
  • Phone: 636-265-1505
  • Fax: 636-266-2112
Mailing address:
  • Phone: 636-265-1505
  • Fax: 636-266-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2008005693
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: