Provider Demographics
NPI:1235125857
Name:BLAKE, MICHELLE L (LMT)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 EWALD AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-3811
Mailing Address - Country:US
Mailing Address - Phone:503-391-1092
Mailing Address - Fax:503-363-7424
Practice Address - Street 1:580 EWALD AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-3811
Practice Address - Country:US
Practice Address - Phone:503-391-1092
Practice Address - Fax:503-363-7424
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4657225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist