Provider Demographics
NPI:1518181320
Name:BLACKMAN, SUSAN KLINT
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KLINT
Last Name:BLACKMAN
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 1:2261 US HIGHWAY 67
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-9694
Mailing Address - Country:US
Mailing Address - Phone:309-734-7902
Mailing Address - Fax:309-734-7114
Practice Address - Street 1:1220 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-2404
Practice Address - Country:US
Practice Address - Phone:309-734-7902
Practice Address - Fax:309-734-7114
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILSB22990398P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty