Basic Information
| Provider Information | |||||||||
| NPI: | 1972917367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKLEDGE | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | ELISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLIFIELD | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | ELISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015839464 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 OLD CORINTH RD | ||||||||
| Address2: | |||||||||
| City: | PETAL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394652932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015839464 | ||||||||
| FaxNumber: | 6015839465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2014 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 05538733 | 05 | MS | MEDICAID |