Provider Demographics
NPI:1073128419
Name:BLACKWELL, MESHA RENA
Entity Type:Individual
Prefix:
First Name:MESHA
Middle Name:RENA
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 RENAISSANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-4800
Mailing Address - Country:US
Mailing Address - Phone:331-262-0101
Mailing Address - Fax:
Practice Address - Street 1:410 RENAISSANCE BLVD
Practice Address - Street 2:
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-4800
Practice Address - Country:US
Practice Address - Phone:331-262-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227013953225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist