Healthcare Provider Details

I. General information

NPI: 1447464557
Provider Name (Legal Business Name): SHANNON LEIGH BLUM ATC, PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W COMMERCE DR STE 100
FESTUS MO
63028-2392
US

IV. Provider business mailing address

647 SPIRIT AIRPARK WEST DR STE 101
CHESTERFIELD MO
63005-1032
US

V. Phone/Fax

Practice location:
  • Phone: 636-224-7511
  • Fax:
Mailing address:
  • Phone: 636-206-4225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number113979
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2019027232
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: