Provider Demographics
NPI:1235493024
Name:BLAKE, JOAN (SLP)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:SLP
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 270431
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75027-0431
Mailing Address - Country:US
Mailing Address - Phone:817-846-9144
Mailing Address - Fax:972-874-1078
Practice Address - Street 1:7400 HAWK RD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-6270
Practice Address - Country:US
Practice Address - Phone:817-846-9144
Practice Address - Fax:972-874-1078
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100983235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist