Basic Information
Provider Information
NPI: 1538347810
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BLASA
FirstName: TIFFANY
MiddleName:  
NamePrefix: MRS.
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 16870 NORTH HARMONY LANE
Address2:  
City: MT VERNON
State: IL
PostalCode: 62864
CountryCode: US
TelephoneNumber: 6189788456
FaxNumber: 6185484902
Practice Location
Address1: 1201 RICKER RD
Address2:  
City: SALEM
State: IL
PostalCode: 628814263
CountryCode: US
TelephoneNumber: 6185483194
FaxNumber:  
Other Information
ProviderEnumerationDate: 02/08/2008
LastUpdateDate: 02/08/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
172V00000X ILY Other Service ProvidersCommunity Health Worker 

No ID Information.


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