Provider Demographics
NPI:1336820265
Name:LABLUE, GERARD (PT)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:
Last Name:LABLUE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 W BAYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5722
Mailing Address - Country:US
Mailing Address - Phone:916-226-9266
Mailing Address - Fax:
Practice Address - Street 1:1709 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-9213
Practice Address - Country:US
Practice Address - Phone:309-321-8393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.027475225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist