Provider Demographics
NPI:1104862754
Name:BLAIR, SUSAN SLOCUM (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:SLOCUM
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 THACKERY CT
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-3175
Mailing Address - Country:US
Mailing Address - Phone:630-904-8152
Mailing Address - Fax:
Practice Address - Street 1:857 CENTER CT
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60431-8520
Practice Address - Country:US
Practice Address - Phone:815-730-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics