Provider Demographics
NPI:1184177610
Name:BLAAUWENDRAAT, NIKITA
Entity type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:BLAAUWENDRAAT
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:PO BOX 833
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-0833
Mailing Address - Country:US
Mailing Address - Phone:419-447-7203
Mailing Address - Fax:
Practice Address - Street 1:27 ST LAWRENCE DR STE 104
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8313
Practice Address - Country:US
Practice Address - Phone:419-455-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.2017027-SP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist