Provider Demographics
NPI:1376039131
Name:BLAKE, ALLI
Entity Type:Individual
Prefix:
First Name:ALLI
Middle Name:
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 1:3132 SE MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-9586
Mailing Address - Country:US
Mailing Address - Phone:605-759-3947
Mailing Address - Fax:
Practice Address - Street 1:9346 OAK AVE
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-9422
Practice Address - Country:US
Practice Address - Phone:952-223-2506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0925102251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics