Provider Demographics
NPI:1316472616
Name:RUSSELL, BLAKE PHILLIPS (MPT)
Entity type:Individual
Prefix:MRS
First Name:BLAKE
Middle Name:PHILLIPS
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-3219
Mailing Address - Country:US
Mailing Address - Phone:831-917-9886
Mailing Address - Fax:
Practice Address - Street 1:220 COUNTRY CLUB GATE CTR
Practice Address - Street 2:SUITE 11
Practice Address - City:PACIFIC GROVE
Practice Address - State:CA
Practice Address - Zip Code:93950-5014
Practice Address - Country:US
Practice Address - Phone:831-917-9886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist