Provider Demographics
NPI:1669827648
Name:BLYLER, JUSTINE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:BLYLER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-1408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 E LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-9501
Practice Address - Country:US
Practice Address - Phone:715-483-2713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3999235Z00000X
MN6243235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist