Provider Demographics
NPI:1851095798
Name:BLALOCK, SHELBY BELLE
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:BELLE
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3623 KIRKLAND LN
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MS
Mailing Address - Zip Code:39645-6002
Mailing Address - Country:US
Mailing Address - Phone:769-244-2908
Mailing Address - Fax:
Practice Address - Street 1:3623 KIRKLAND LN
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MS
Practice Address - Zip Code:39645-6002
Practice Address - Country:US
Practice Address - Phone:769-244-2908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS6199225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty