Provider Demographics
NPI:1164759981
Name:BLAKE, ANDREA (DC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5977
Mailing Address - Street 2:DEPT. 20-3059
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60197-5977
Mailing Address - Country:US
Mailing Address - Phone:630-468-1831
Mailing Address - Fax:630-701-1007
Practice Address - Street 1:2410 W JEFFERSON ST
Practice Address - Street 2:STE 116
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6449
Practice Address - Country:US
Practice Address - Phone:630-468-1831
Practice Address - Fax:630-701-1007
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011465111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor