Provider Demographics
NPI:1902052004
Name:BLAKE, SANDRA (MHPP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 WHITTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-3407
Mailing Address - Country:US
Mailing Address - Phone:501-623-3477
Mailing Address - Fax:501-624-7498
Practice Address - Street 1:3871 SPRING ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-8606
Practice Address - Country:US
Practice Address - Phone:501-623-3477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AR057935310994E3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant