Provider Demographics
NPI:1275182941
Name:BLAKE, SHARON A
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:A
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2980 W BEAUMONT LN
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-2071
Mailing Address - Country:US
Mailing Address - Phone:773-837-2921
Mailing Address - Fax:
Practice Address - Street 1:606 S 9TH ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6320
Practice Address - Country:US
Practice Address - Phone:352-805-4404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT107092251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14535847Medicaid