Provider Demographics
NPI:1396223129
Name:BLAKE, KELLY JAMES (OTR)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JAMES
Last Name:BLAKE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3257 WHITFIELD CT
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-2769
Mailing Address - Country:US
Mailing Address - Phone:248-330-1770
Mailing Address - Fax:
Practice Address - Street 1:1901 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-1878
Practice Address - Country:US
Practice Address - Phone:248-836-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004341225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist