Provider Demographics
NPI:1538381868
Name:BLAKE, LIZANNE P
Entity type:Individual
Prefix:
First Name:LIZANNE
Middle Name:P
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 RCA BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-3338
Mailing Address - Country:US
Mailing Address - Phone:561-373-8946
Mailing Address - Fax:561-627-2204
Practice Address - Street 1:2560 RCA BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-3338
Practice Address - Country:US
Practice Address - Phone:561-373-8946
Practice Address - Fax:561-627-2204
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 2313235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist