Provider Demographics
NPI:1104493089
Name:MANN, BLAKE CHARLES (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:CHARLES
Last Name:MANN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 S SPINNAKER LN
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:DE
Mailing Address - Zip Code:19968-1538
Mailing Address - Country:US
Mailing Address - Phone:302-500-2294
Mailing Address - Fax:
Practice Address - Street 1:1255 S STATE ST STE 7
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-6932
Practice Address - Country:US
Practice Address - Phone:302-734-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0014376225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty