Provider Demographics
NPI:1083728893
Name:BLODGETT, DEBRA JOY (DC)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:JOY
Last Name:BLODGETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-1867
Mailing Address - Country:US
Mailing Address - Phone:262-673-6764
Mailing Address - Fax:262-673-6845
Practice Address - Street 1:23 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-1867
Practice Address - Country:US
Practice Address - Phone:262-673-6764
Practice Address - Fax:262-673-6845
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3293111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38892400Medicaid
WI38892400Medicaid