=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942049085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH BLAKELY ALLEN PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2024
-----------------------------------------------------
Last Update Date | 05/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 CAMELLIA BLVD BLDG C
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70508-6393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-456-6148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 CAMELLIA BLVD BLDG C
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70508-6393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-456-6148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A11772
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------