Provider Demographics
NPI:1962209742
Name:BLAKE, ERNESTINE TINA (LMT)
Entity type:Individual
Prefix:
First Name:ERNESTINE
Middle Name:TINA
Last Name:BLAKE
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 460301
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80046-0301
Mailing Address - Country:US
Mailing Address - Phone:303-505-7763
Mailing Address - Fax:
Practice Address - Street 1:2670 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80126-3231
Practice Address - Country:US
Practice Address - Phone:303-505-7763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-27
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0025655225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist