Provider Demographics
NPI:1174954648
Name:BLADES, KERRIE (DPT)
Entity type:Individual
Prefix:
First Name:KERRIE
Middle Name:
Last Name:BLADES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14900 PETE DYE ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-6333
Mailing Address - Country:US
Mailing Address - Phone:951-315-5307
Mailing Address - Fax:
Practice Address - Street 1:14900 PETE DYE ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-6333
Practice Address - Country:US
Practice Address - Phone:951-315-5307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist