Provider Demographics
NPI:1114992963
Name:BLOUNT, VICTORIA L (CCC-A)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:L
Other - Last Name:KYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-A
Mailing Address - Street 1:PO BOX 19662
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9662
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-0253
Practice Address - Street 1:301 N 8TH ST # 5B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1041
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-0253
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000929231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL147-000929OtherSTATE LICENSE
Q28886Medicare UPIN
IL147-000929OtherSTATE LICENSE