Provider Demographics
NPI:1205415502
Name:DUNHAM, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:DUNHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2367 STATE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4505
Mailing Address - Country:US
Mailing Address - Phone:503-568-2854
Mailing Address - Fax:971-600-9079
Practice Address - Street 1:2367 STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4505
Practice Address - Country:US
Practice Address - Phone:503-568-2854
Practice Address - Fax:971-600-9079
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18560225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist