Provider Demographics
NPI:1467960542
Name:BLAKE, MONTERRICA E (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MONTERRICA
Middle Name:E
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313B BLUEBIRD DR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-2303
Mailing Address - Country:US
Mailing Address - Phone:615-448-6446
Mailing Address - Fax:615-467-8825
Practice Address - Street 1:313B BLUEBIRD DR
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-2303
Practice Address - Country:US
Practice Address - Phone:615-448-6446
Practice Address - Fax:615-467-8825
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10714532225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist