Provider Demographics
NPI:1336318633
Name:BLAKE, HEIDI ANN
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:ANN
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 1:234 BIRCHTREE DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-1502
Mailing Address - Country:US
Mailing Address - Phone:864-223-0900
Mailing Address - Fax:
Practice Address - Street 1:234 BIRCHTREE DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-1502
Practice Address - Country:US
Practice Address - Phone:864-223-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4057208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation