Provider Demographics
NPI:1982473419
Name:BLACKWELL, TIMOTHY ERIC (PTA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ERIC
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1765 OLD WEST BROAD ST BLDG 2-200
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2887
Mailing Address - Country:US
Mailing Address - Phone:706-549-1663
Mailing Address - Fax:706-546-8792
Practice Address - Street 1:1031 LAKE COUNTRY DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-5157
Practice Address - Country:US
Practice Address - Phone:706-549-1663
Practice Address - Fax:706-546-8792
Is Sole Proprietor?:No
Enumeration Date:2023-12-26
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA001092225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
16096608OtherCAQH #