Provider Demographics
NPI:1215387212
Name:BLAKE, SUSAN (OTR)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 MISSIONARY RD
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2170
Mailing Address - Country:US
Mailing Address - Phone:860-754-3033
Mailing Address - Fax:
Practice Address - Street 1:52 MISSIONARY RD
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2170
Practice Address - Country:US
Practice Address - Phone:860-754-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002595225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist