Provider Demographics
NPI:1528435955
Name:BLATT, ALEXA (ATC)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:BLATT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 S MAIN ST
Mailing Address - Street 2:APT 413
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-4477
Mailing Address - Country:US
Mailing Address - Phone:818-631-1564
Mailing Address - Fax:
Practice Address - Street 1:180 N ADELAIDE ST
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2404
Practice Address - Country:US
Practice Address - Phone:309-438-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0040462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer