Provider Demographics
NPI:1336656263
Name:BLAKE, MOSI (L/ATC)
Entity Type:Individual
Prefix:MR
First Name:MOSI
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:L/ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13020 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0925
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:813-558-6187
Practice Address - Street 1:305 E BRANDON BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5222
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-558-6187
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-31
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL29282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty