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General NPI Number Information
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NPI Number | 1760746648
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Entity Type | Individual
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Provider Name | TRINA NICOLE BLACKWOOD MOTR/L
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Gender | Female
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Dates
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Enumeration Date | 06/26/2012
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Last Update Date | 12/19/2022
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Provider Practice Location Address
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Address Line | 101 CHAPEL GROVE CT
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City | WENTZVILLE
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State | MO
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Zip | 63385-4339
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Country | US
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Telephone | 636-443-5379
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Fax |
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Provider Business Mailing Address
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Address Line | 101 CHAPEL GROVE CT
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City | WENTZVILLE
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State | MO
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Zip | 63385-4339
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Country | US
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Telephone | 636-443-5379
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | 2011022964
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License Number State | MO
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