Provider Demographics
NPI:1366019259
Name:KOLB, BLYTHE (PTA)
Entity type:Individual
Prefix:
First Name:BLYTHE
Middle Name:
Last Name:KOLB
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:BLYTHE
Other - Middle Name:
Other - Last Name:DEWALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1981 SW AARON LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2127
Mailing Address - Country:US
Mailing Address - Phone:772-342-3834
Mailing Address - Fax:
Practice Address - Street 1:3005 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-9045
Practice Address - Country:US
Practice Address - Phone:772-342-3834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27229225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant