Provider Demographics
NPI:1295560100
Name:BLAKE, MICHAEL JACK (DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JACK
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 S WILCOX ST STE B
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-1951
Mailing Address - Country:US
Mailing Address - Phone:303-839-8068
Mailing Address - Fax:303-835-3597
Practice Address - Street 1:390 S WILCOX ST STE B
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1951
Practice Address - Country:US
Practice Address - Phone:303-839-8068
Practice Address - Fax:303-835-3597
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501303478225100000X
CO20757225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist