Provider Demographics
NPI:1720813835
Name:BLAKE, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:65 WEEKS DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MO
Mailing Address - Zip Code:65622-4116
Mailing Address - Country:US
Mailing Address - Phone:417-619-4640
Mailing Address - Fax:
Practice Address - Street 1:1323 S ASH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MO
Practice Address - Zip Code:65622-9311
Practice Address - Country:US
Practice Address - Phone:417-345-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016764224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty