Provider Demographics
NPI:1376619155
Name:BLAVAT, RENNA KAY (MPT)
Entity Type:Individual
Prefix:MRS
First Name:RENNA
Middle Name:KAY
Last Name:BLAVAT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14762 309TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-8515
Mailing Address - Country:US
Mailing Address - Phone:763-389-8961
Mailing Address - Fax:
Practice Address - Street 1:911 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-2172
Practice Address - Country:US
Practice Address - Phone:763-389-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6434225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist