Provider Demographics
NPI:1114139938
Name:BLAKESLEY, COREY R (MSPT)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:R
Last Name:BLAKESLEY
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MAPLECREST DR
Mailing Address - Street 2:
Mailing Address - City:RAVENA
Mailing Address - State:NY
Mailing Address - Zip Code:12143-9753
Mailing Address - Country:US
Mailing Address - Phone:518-469-7122
Mailing Address - Fax:
Practice Address - Street 1:71 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2907
Practice Address - Country:US
Practice Address - Phone:518-828-7601
Practice Address - Fax:518-828-8772
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025456-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY330094Medicare ID - Type Unspecified