Healthcare Provider Details

I. General information

NPI: 1538347810
Provider Name (Legal Business Name): TIFFANY BLASA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 RICKER RD
SALEM IL
62881-4263
US

IV. Provider business mailing address

16870 NORTH HARMONY LANE
MT VERNON IL
62864
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-3194
  • Fax:
Mailing address:
  • Phone: 618-978-8456
  • Fax: 618-548-4902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: