Provider Demographics
NPI:1811669310
Name:BLACKMAN, TEARZA MANNEAH (LMT)
Entity type:Individual
Prefix:
First Name:TEARZA
Middle Name:MANNEAH
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 6TH ST
Mailing Address - Street 2:
Mailing Address - City:KERSEY
Mailing Address - State:CO
Mailing Address - Zip Code:80644-9782
Mailing Address - Country:US
Mailing Address - Phone:907-795-8864
Mailing Address - Fax:
Practice Address - Street 1:709 6TH ST
Practice Address - Street 2:
Practice Address - City:KERSEY
Practice Address - State:CO
Practice Address - Zip Code:80644-9782
Practice Address - Country:US
Practice Address - Phone:907-795-8864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0021737225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist