Provider Demographics
NPI:1508288135
Name:BLAKE, TIMOTHY (BS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 ELM ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4522
Mailing Address - Country:US
Mailing Address - Phone:775-329-7017
Mailing Address - Fax:775-323-0749
Practice Address - Street 1:343 ELM ST
Practice Address - Street 2:SUITE 204
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4522
Practice Address - Country:US
Practice Address - Phone:775-329-7017
Practice Address - Fax:775-323-0749
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV283237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist