Provider Demographics
NPI:1851388631
Name:BLUM, JUDITH A (OTR)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:BLUM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2356
Mailing Address - Country:US
Mailing Address - Phone:715-526-7370
Mailing Address - Fax:715-526-7294
Practice Address - Street 1:116 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2356
Practice Address - Country:US
Practice Address - Phone:715-526-7370
Practice Address - Fax:715-526-7294
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1862-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40717500Medicaid