Provider Demographics
NPI:1073373411
Name:BLASSINGHAM, MALLORY N (DPT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:N
Last Name:BLASSINGHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:N
Other - Last Name:SCHILF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2662 MCFARLAND RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6806
Mailing Address - Country:US
Mailing Address - Phone:815-227-1700
Mailing Address - Fax:815-227-1744
Practice Address - Street 1:209 N UNION ST
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:IL
Practice Address - Zip Code:61010-8626
Practice Address - Country:US
Practice Address - Phone:815-234-5553
Practice Address - Fax:815-234-5557
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.028112225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist