Provider Demographics
NPI:1386124139
Name:BLAKE, MELISSA A (OTR)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:BLAKE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3257 WHITFIELD CT
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-2769
Mailing Address - Country:US
Mailing Address - Phone:248-412-3826
Mailing Address - Fax:
Practice Address - Street 1:3257 WHITFIELD CT
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329
Practice Address - Country:US
Practice Address - Phone:248-412-3826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007148225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist