Provider Demographics
NPI:1033112073
Name:VAN BLARICOM, DESIREE (PT)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:VAN BLARICOM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 S CRYSTAL ST
Mailing Address - Street 2:STE 400
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1506
Mailing Address - Country:US
Mailing Address - Phone:406-496-3456
Mailing Address - Fax:406-496-3457
Practice Address - Street 1:435 S CRYSTAL ST
Practice Address - Street 2:STE 400
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1506
Practice Address - Country:US
Practice Address - Phone:406-496-3456
Practice Address - Fax:406-496-3457
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT50798Medicare ID - Type UnspecifiedPT