Provider Demographics
NPI:1831159318
Name:BLATT, SUSAN L (CH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:BLATT
Suffix:
Gender:F
Credentials:CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:367 N MAIN ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:EAGAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85925-9676
Mailing Address - Country:US
Mailing Address - Phone:928-333-4757
Mailing Address - Fax:928-333-4757
Practice Address - Street 1:367 N MAIN ST
Practice Address - Street 2:SUITE 9
Practice Address - City:EAGAR
Practice Address - State:AZ
Practice Address - Zip Code:85925-9676
Practice Address - Country:US
Practice Address - Phone:928-333-4757
Practice Address - Fax:928-333-4757
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ7405111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z77118Medicare PIN