Provider Demographics
NPI:1609480763
Name:KREISHER, BLAISE S
Entity Type:Individual
Prefix:
First Name:BLAISE
Middle Name:S
Last Name:KREISHER
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 1:10007 LENOX ST
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-9114
Mailing Address - Country:US
Mailing Address - Phone:352-321-9171
Mailing Address - Fax:
Practice Address - Street 1:10007 LENOX ST
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-9114
Practice Address - Country:US
Practice Address - Phone:352-321-9171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9752235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist