Provider Demographics
NPI:1356679088
Name:BLAKE, TOMICA D (MT)
Entity Type:Individual
Prefix:
First Name:TOMICA
Middle Name:D
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:TOMICA
Other - Middle Name:D
Other - Last Name:HARPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MT
Mailing Address - Street 1:5000 TOWN CTR
Mailing Address - Street 2:SUITE 2001
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-1110
Mailing Address - Country:US
Mailing Address - Phone:586-685-0505
Mailing Address - Fax:
Practice Address - Street 1:16801 NEWBURGH RD
Practice Address - Street 2:SUITE 114
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1606
Practice Address - Country:US
Practice Address - Phone:248-910-3644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist