Provider Demographics
NPI:1548715402
Name:SPECIALTY REHAB & WELLNESS
Entity type:Organization
Organization Name:SPECIALTY REHAB & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L, CLT
Authorized Official - Phone:314-313-1088
Mailing Address - Street 1:3309 CRYSTAL LAKE DR
Mailing Address - Street 2:FESTUS
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4274
Mailing Address - Country:US
Mailing Address - Phone:314-313-1088
Mailing Address - Fax:
Practice Address - Street 1:3309 CRYSTAL LAKE DR
Practice Address - Street 2:FESTUS
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4274
Practice Address - Country:US
Practice Address - Phone:314-313-1088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000175372261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation