Provider Demographics
NPI:1467872226
Name:BLUNT, MICHELE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:BLUNT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 HUNTERS TRL
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-2768
Mailing Address - Country:US
Mailing Address - Phone:618-604-6680
Mailing Address - Fax:
Practice Address - Street 1:1131 HUNTERS TRL
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-2768
Practice Address - Country:US
Practice Address - Phone:618-604-6680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-006600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist