Provider Demographics
NPI:1891241543
Name:BLAVOS, RACHEL ELLEN (PT, DPT)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ELLEN
Last Name:BLAVOS
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 1:5310 CHASTAIN DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4178
Mailing Address - Country:US
Mailing Address - Phone:228-235-0348
Mailing Address - Fax:
Practice Address - Street 1:1835 SAVOY DR
Practice Address - Street 2:#101B
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-1072
Practice Address - Country:US
Practice Address - Phone:678-298-9484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012457225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist