Provider Demographics
NPI:1093121345
Name:BLAKE, SANDRA (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:MARIE
Other - Last Name:DEVITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP-CCC
Mailing Address - Street 1:36 CORNELL ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2009
Mailing Address - Country:US
Mailing Address - Phone:646-733-7560
Mailing Address - Fax:
Practice Address - Street 1:36 CORNELL ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-2009
Practice Address - Country:US
Practice Address - Phone:646-733-7560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist