Provider Demographics
NPI:1720344005
Name:BLAKE, MATTHEW CLARK (COTA/L)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CLARK
Last Name:BLAKE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WYANT RD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-4228
Mailing Address - Country:US
Mailing Address - Phone:330-926-7221
Mailing Address - Fax:
Practice Address - Street 1:200 WYANT RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313
Practice Address - Country:US
Practice Address - Phone:330-926-7221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant