MEDICARE: VICTORIA BLACKMON OCCUPATION THERAPY

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	224Z00000X	Occupational Therapy Assistant		IL

General Provider Information

NPI Number	:	1396368114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA BLACKMON OCCUPATION THERAPY

Provider Business Mailing Address
First Line	:	12742 DIVISION ST UNIT 1
Second Line	:
City	:	BLUE ISLAND
State	:	IL
Zip	:	60406-3476
Country	:	US
Telephone Number	:	708-833-3566
Fax Number	:

Provider Business Practice Location Address
First Line	:	12742 DIVISION ST UNIT 1
Second Line	:
City	:	BLUE ISLAND
State	:	IL
Zip	:	60406-3476
Country	:	US
Telephone Number	:	708-833-3566
Fax Number	:

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

Provider Enumeration Date	:	05/27/2020
Last Update Date	:	05/27/2020

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Directions to “ VICTORIA BLACKMON OCCUPATION THERAPY” Practice Location

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