MEDICARE: DANA RENAE BLAHUTA O.T.R

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	225X00000X	Occupational Therapist	107370	TX

General Provider Information

NPI Number	:	1962568295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANA RENAE BLAHUTA O.T.R

Provider Business Mailing Address
First Line	:	1330 COUNTY ROAD 265
Second Line	:
City	:	MOULTON
State	:	TX
Zip	:	77975-4887
Country	:	US
Telephone Number	:	361-596-7441
Fax Number	:	979-743-2185

Provider Business Practice Location Address
First Line	:	111 COLLEGE ST
Second Line	:
City	:	SCHULENBURG
State	:	TX
Zip	:	78956-1601
Country	:	US
Telephone Number	:	979-743-6537
Fax Number	:	979-743-2185

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

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	07/08/2007

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