Healthcare Provider Details

I. General information

NPI: 1063979979
Provider Name (Legal Business Name): CHERYL ANN BLAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ACORN LN
MUNDELEIN IL
60060-4019
US

IV. Provider business mailing address

17273 W DARTMOOR DR
GRAYSLAKE IL
60030-3010
US

V. Phone/Fax

Practice location:
  • Phone: 847-566-9221
  • Fax:
Mailing address:
  • Phone: 847-845-8798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.002558
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: