Provider Demographics
NPI:1114928868
Name:BLAKE, BEVAN D (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BEVAN
Middle Name:D
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 E SOUTH TEMPLE
Mailing Address - Street 2:#250
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1206
Mailing Address - Country:US
Mailing Address - Phone:801-512-2656
Mailing Address - Fax:801-906-0336
Practice Address - Street 1:370 E SOUTH TEMPLE
Practice Address - Street 2:#250
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1206
Practice Address - Country:US
Practice Address - Phone:801-512-2656
Practice Address - Fax:801-906-0336
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT344859-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT64-00731OtherUNITED HEALTHCARE
UT68963OtherPEHP
UT870388269BR1OtherEDUCATORS MUTUAL
UTCJ9402OtherRAILROAD MEDICARE
UT34485924000001OtherBLUE CROSS BLUE SHIELD
UT5417OtherDMBA
UTP53978Medicare UPIN
UT34485924000001OtherBLUE CROSS BLUE SHIELD