Provider Demographics
NPI:1215988605
Name:BLACKLEY, MARK WILLIAM (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:BLACKLEY
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
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Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR, ATTN: CREDENTIALS OFFICE
Mailing Address - Street 2:USA MEDDAC, EVANS ARMY COMMUNITY HOSPITAL
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4604
Mailing Address - Country:US
Mailing Address - Phone:719-526-7844
Mailing Address - Fax:719-526-7984
Practice Address - Street 1:PHYSICAL THERAPY CLINIC
Practice Address - Street 2:USA MEDDAC, EVANS ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4604
Practice Address - Country:US
Practice Address - Phone:719-526-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO27882251E1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical