Provider Demographics
NPI:1316050438
Name:BLAKE, KATHLEEN (DC)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2765
Mailing Address - Country:US
Mailing Address - Phone:862-209-4888
Mailing Address - Fax:862-209-4889
Practice Address - Street 1:60 BROADWAY
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2765
Practice Address - Country:US
Practice Address - Phone:862-209-4888
Practice Address - Fax:862-209-4889
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00463500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ089403DHNMedicare ID - Type Unspecified
NJT89861Medicare UPIN