Healthcare Provider Details

I. General information

NPI: 1144437138
Provider Name (Legal Business Name): LORI BLAHNIK MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORI LOWE

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W MAIN ST
MADISON WI
53715-1424
US

IV. Provider business mailing address

25 KESSEL CT STE 105
MADISON WI
53711-6227
US

V. Phone/Fax

Practice location:
  • Phone: 608-280-2580
  • Fax:
Mailing address:
  • Phone: 608-280-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number93741
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3591-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: