Provider Demographics
NPI:1467095786
Name:HAMOUDA, BLAKE (LMT AND MMP)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:HAMOUDA
Suffix:
Gender:M
Credentials:LMT AND MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14848 N 113TH PL
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-1867
Mailing Address - Country:US
Mailing Address - Phone:480-450-3532
Mailing Address - Fax:
Practice Address - Street 1:14848 N 113TH PL
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-1867
Practice Address - Country:US
Practice Address - Phone:480-450-3532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-26039225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist