Provider Demographics
NPI:1487873378
Name:BLAKE, BRANDY L (LMP)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8411 110TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-6002
Mailing Address - Country:US
Mailing Address - Phone:206-940-7226
Mailing Address - Fax:253-826-8180
Practice Address - Street 1:8411 110TH STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-6002
Practice Address - Country:US
Practice Address - Phone:206-940-7226
Practice Address - Fax:253-826-8180
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018865225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist