Healthcare Provider Details

I. General information

NPI: 1104862754
Provider Name (Legal Business Name): SUSAN SLOCUM BLAIR PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

857 CENTER CT
SHOREWOOD IL
60431-8520
US

IV. Provider business mailing address

1207 THACKERY CT
NAPERVILLE IL
60564-3175
US

V. Phone/Fax

Practice location:
  • Phone: 815-730-1818
  • Fax:
Mailing address:
  • Phone: 630-904-8152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: