Provider Demographics
NPI:1316459886
Name:BLAZEK, KRISTEN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:
Last Name:BLAZEK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:WHITE ROCK
Mailing Address - State:SC
Mailing Address - Zip Code:29177-0444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2101 DUTCH FORK RD
Practice Address - Street 2:
Practice Address - City:WHITE ROCK
Practice Address - State:SC
Practice Address - Zip Code:29177
Practice Address - Country:US
Practice Address - Phone:803-732-8790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist