Provider Demographics
NPI:1538453360
Name:ZIKRATCH-CLAYSON, BLAIRE M (DPT)
Entity type:Individual
Prefix:
First Name:BLAIRE
Middle Name:M
Last Name:ZIKRATCH-CLAYSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BLAIRE
Other - Middle Name:
Other - Last Name:THOMSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:335 E LEWIS ST
Mailing Address - Street 2:STE 10
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-269-2360
Mailing Address - Fax:208-550-3256
Practice Address - Street 1:335 E LEWIS ST
Practice Address - Street 2:STE 10
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-269-2360
Practice Address - Fax:208-550-3256
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2831225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist