Provider Demographics
NPI:1669780276
Name:BLAIR, WILLIE J (OT)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:J
Last Name:BLAIR
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5026 CAPRI LN
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5026 CAPRI LN
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1193
Practice Address - Country:US
Practice Address - Phone:877-974-6383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056004034225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist