Provider Demographics
NPI:1992157549
Name:WELLS, BLAKE (PTA)
Entity type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11503 SUMMER HAVEN BLVD NORTH
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258
Mailing Address - Country:US
Mailing Address - Phone:702-237-9835
Mailing Address - Fax:
Practice Address - Street 1:803 OAK STREET
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043
Practice Address - Country:US
Practice Address - Phone:904-284-5568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26587225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant