Provider Demographics
NPI:1962960492
Name:BLAKE, PATRICIA ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:ANN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 NORTHPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-6072
Mailing Address - Country:US
Mailing Address - Phone:207-338-4076
Mailing Address - Fax:207-505-4754
Practice Address - Street 1:118 NORTHPORT AVE
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6072
Practice Address - Country:US
Practice Address - Phone:207-338-4076
Practice Address - Fax:207-505-4754
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA70000021225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist