1821159591 NPI number — DEBRA LYNN BLISS OTR-L

Table of content: DEBRA LYNN BLISS OTR-L (NPI 1821159591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821159591 NPI number — DEBRA LYNN BLISS OTR-L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLISS
Provider First Name:
DEBRA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR-L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821159591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 WELSH COBB CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE HEATH
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61884-9702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-687-4175
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 S STALEY RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61822-9234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-493-4175
Provider Business Practice Location Address Fax Number:
217-351-6486
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07432001 . This is a "BLUE CROSS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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