Provider Demographics
NPI:1669944435
Name:BLANKENSHIP, BETH M (PTA/L)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:M
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:PTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 W CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8306 SAINT LUKES DR
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-8384
Practice Address - Country:US
Practice Address - Phone:217-323-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005251225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant