Healthcare Provider Details

I. General information

NPI: 1477483659
Provider Name (Legal Business Name): LESLEY LORAINE BLUM OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 S PRINCE ST
WHITEWATER WI
53190-1726
US

IV. Provider business mailing address

213 ESTATE CT
ELKHORN WI
53121-2214
US

V. Phone/Fax

Practice location:
  • Phone: 262-472-8500
  • Fax:
Mailing address:
  • Phone: 262-903-9214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number119095
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: