Healthcare Provider Details

I. General information

NPI: 1386765295
Provider Name (Legal Business Name): MRS. INGRID BLAHUT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2422 W MAIN ST
ST CHARLES IL
60175-1010
US

IV. Provider business mailing address

40W325 CARL SANDBURG RD
ST CHARLES IL
60175-7737
US

V. Phone/Fax

Practice location:
  • Phone: 630-513-5012
  • Fax: 630-513-1957
Mailing address:
  • Phone: 630-513-5012
  • Fax: 630-513-1957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: