Healthcare Provider Details

I. General information

NPI: 1114992963
Provider Name (Legal Business Name): VICTORIA L BLOUNT CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VICTORIA L KYLE CCC-A

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 8TH ST # 5B
SPRINGFIELD IL
62701-1041
US

IV. Provider business mailing address

PO BOX 19662
SPRINGFIELD IL
62794-9662
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-0253
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-0253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147000929
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: