Provider Demographics
NPI:1114310158
Name:BALDWIN, BLAKE (PTA)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2544 JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4202
Mailing Address - Country:US
Mailing Address - Phone:314-568-8381
Mailing Address - Fax:
Practice Address - Street 1:5400 EXECUTIVE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2594
Practice Address - Country:US
Practice Address - Phone:636-447-1098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014037263225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant