Provider Demographics
NPI:1033853692
Name:VONDERHAAR, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:VONDERHAAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BLAKE
Other - Middle Name:
Other - Last Name:FISHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5875 E SENOUR DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-1396
Mailing Address - Country:US
Mailing Address - Phone:513-907-4290
Mailing Address - Fax:
Practice Address - Street 1:6475 LESOURDSVILLE WEST CHESTER RD
Practice Address - Street 2:
Practice Address - City:LIBERTY TWP
Practice Address - State:OH
Practice Address - Zip Code:45011-8455
Practice Address - Country:US
Practice Address - Phone:513-644-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.14887235Z00000X
OHCOND.20211810-SP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist