Provider Demographics
NPI:1881277077
Name:BLUM, MALISSA ROSE II (COTA)
Entity type:Individual
Prefix:
First Name:MALISSA
Middle Name:ROSE
Last Name:BLUM
Suffix:II
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 OAK BLUFF TER
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:IL
Mailing Address - Zip Code:61373-9509
Mailing Address - Country:US
Mailing Address - Phone:815-830-3994
Mailing Address - Fax:
Practice Address - Street 1:154 OAK BLUFF TER
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:IL
Practice Address - Zip Code:61373-9509
Practice Address - Country:US
Practice Address - Phone:815-830-3994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty