Provider Demographics
NPI:1922676246
Name:BLODGETT, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BLODGETT
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 1:1005 PINEGROVE DR APT 202
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7398
Mailing Address - Country:US
Mailing Address - Phone:256-508-7952
Mailing Address - Fax:
Practice Address - Street 1:3650 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1036
Practice Address - Country:US
Practice Address - Phone:616-669-1520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5502006379225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant