Provider Demographics
NPI:1134470453
Name:BLOTSKE, SHANNON MICHELLE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:BLOTSKE
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 1:14457 APPLE DR
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SD
Mailing Address - Zip Code:57769-2101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 TEXAS ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7319
Practice Address - Country:US
Practice Address - Phone:605-342-0255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0435225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist