Provider Demographics
NPI:1871926410
Name:BLAYLOCK, LAURA (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3124 N SWAN RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1227
Mailing Address - Country:US
Mailing Address - Phone:520-325-4002
Mailing Address - Fax:520-325-4227
Practice Address - Street 1:216 CHANTILLY DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-4704
Practice Address - Country:US
Practice Address - Phone:318-376-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist