Provider Demographics
NPI:1285147959
Name:VANBLARICUM, KATIE BRIANNA
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:BRIANNA
Last Name:VANBLARICUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1367 E IL 250
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:IL
Mailing Address - Zip Code:62868-2400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 SHADWELL AVE
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-2310
Practice Address - Country:US
Practice Address - Phone:618-662-8361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist