Provider Demographics
NPI:1225531486
Name:BLANTON, SHIRLEY (MOT, OTR/L, SCLV)
Entity Type:Individual
Prefix:MISS
First Name:SHIRLEY
Middle Name:
Last Name:BLANTON
Suffix:
Gender:F
Credentials:MOT, OTR/L, SCLV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 573
Mailing Address - Street 2:
Mailing Address - City:BELZONI
Mailing Address - State:MS
Mailing Address - Zip Code:39038-0573
Mailing Address - Country:US
Mailing Address - Phone:662-455-0030
Mailing Address - Fax:662-247-1489
Practice Address - Street 1:706 HIGHWAY 82 W
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-5028
Practice Address - Country:US
Practice Address - Phone:662-455-0030
Practice Address - Fax:662-247-1489
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2022-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1121225X00000X, 225XN1300X, 225XL0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow Vision
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation