Provider Demographics
NPI:1104593599
Name:FALCONELLO, BLAKE JORDAN (DPT)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:JORDAN
Last Name:FALCONELLO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6542 GOODMAN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-5559
Mailing Address - Country:US
Mailing Address - Phone:662-874-5964
Mailing Address - Fax:662-874-5176
Practice Address - Street 1:6542 GOODMAN RD STE 101
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-5559
Practice Address - Country:US
Practice Address - Phone:662-874-5964
Practice Address - Fax:662-874-5176
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist