Provider Demographics
NPI:1215415161
Name:BLATZHEIM, REBECCA (HAS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BLATZHEIM
Suffix:
Gender:F
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 MAIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-5974
Mailing Address - Country:US
Mailing Address - Phone:850-638-9350
Mailing Address - Fax:
Practice Address - Street 1:1611 MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-5974
Practice Address - Country:US
Practice Address - Phone:850-638-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5383237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist