MEDICARE: DESIREE VAN BLARICOM PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1821	MT

General Provider Information

NPI Number	:	1033112073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESIREE VAN BLARICOM PT

Provider Business Mailing Address
First Line	:	435 S CRYSTAL ST
Second Line	:	STE 400
City	:	BUTTE
State	:	MT
Zip	:	59701-1506
Country	:	US
Telephone Number	:	406-496-3456
Fax Number	:	406-496-3457

Provider Business Practice Location Address
First Line	:	435 S CRYSTAL ST
Second Line	:	STE 400
City	:	BUTTE
State	:	MT
Zip	:	59701-1506
Country	:	US
Telephone Number	:	406-496-3456
Fax Number	:	406-496-3457

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	09/19/2007

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