Provider Demographics
NPI:1215322946
Name:MOORE, BLAKELEE ANN
Entity type:Individual
Prefix:MRS
First Name:BLAKELEE
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BLAKELEE
Other - Middle Name:ANN
Other - Last Name:SOILEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4150 NELSON RD
Mailing Address - Street 2:SUITE C12
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4148
Mailing Address - Country:US
Mailing Address - Phone:337-990-5621
Mailing Address - Fax:888-574-7253
Practice Address - Street 1:4150 NELSON RD
Practice Address - Street 2:SUITE C12
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4148
Practice Address - Country:US
Practice Address - Phone:337-990-5621
Practice Address - Fax:888-574-7253
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist