Healthcare Provider Details

I. General information

NPI: 1851079560
Provider Name (Legal Business Name): CATHERINE BLAIR SOUTH PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 N JEFFERSON ST
ROANOKE VA
24016-1427
US

IV. Provider business mailing address

357 SALEM AVE SW APT 112
ROANOKE VA
24016-3643
US

V. Phone/Fax

Practice location:
  • Phone: 540-345-5111
  • Fax:
Mailing address:
  • Phone: 804-824-3962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305215725
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: