Provider Demographics
NPI:1508121385
Name:WISEMAN, BLAKE (DPT)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13426 LOST CREEK LN
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46074-5836
Mailing Address - Country:US
Mailing Address - Phone:317-989-3578
Mailing Address - Fax:
Practice Address - Street 1:890 E 116TH ST
Practice Address - Street 2:SUITE 142
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3475
Practice Address - Country:US
Practice Address - Phone:317-688-8232
Practice Address - Fax:866-512-2250
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009661A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201186570Medicaid