Provider Demographics
NPI:1023621224
Name:CHURCH, BLAIR RENEE (OTR/L)
Entity type:Individual
Prefix:MS
First Name:BLAIR
Middle Name:RENEE
Last Name:CHURCH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 PEQUOT AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4407
Mailing Address - Country:US
Mailing Address - Phone:860-608-5498
Mailing Address - Fax:
Practice Address - Street 1:14 2ND ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5151
Practice Address - Country:US
Practice Address - Phone:203-883-1510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5492225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist