Provider Demographics
NPI:1164201943
Name:BLAKE, CHANEL (COTA)
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 EAST 110TH STREET
Mailing Address - Street 2:SUITE 6D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:646-489-2579
Mailing Address - Fax:
Practice Address - Street 1:123 EAST 110TH STREET
Practice Address - Street 2:SUITE 6D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:646-489-2579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011416-01224Z00000X
NY225100000X, 225X00000X, 235Z00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist