Provider Demographics
NPI:1730485921
Name:BLATTNER, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BLATTNER
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 1:112 S BROADVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5759
Mailing Address - Country:US
Mailing Address - Phone:573-334-3486
Mailing Address - Fax:
Practice Address - Street 1:112 S BROADVIEW ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5759
Practice Address - Country:US
Practice Address - Phone:573-334-3486
Practice Address - Fax:573-334-3524
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090306121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical