Healthcare Provider Details

I. General information

NPI: 1306048764
Provider Name (Legal Business Name): DEIDRE DIONE BLUE P.T., ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 MCCALLIE AVE
CHATTANOOGA TN
37404-3322
US

IV. Provider business mailing address

5750 LAKE RESORT DR APT H107
CHATTANOOGA TN
37415-7045
US

V. Phone/Fax

Practice location:
  • Phone: 423-622-6200
  • Fax:
Mailing address:
  • Phone: 423-877-4723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305212577
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0000005485
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: