Provider Demographics
NPI:1508804428
Name:BLAKE, BRENDON (PT)
Entity Type:Individual
Prefix:MR
First Name:BRENDON
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4754 MARTIN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3507
Mailing Address - Country:US
Mailing Address - Phone:770-967-4377
Mailing Address - Fax:770-967-8077
Practice Address - Street 1:4754 MARTIN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-3507
Practice Address - Country:US
Practice Address - Phone:770-967-4377
Practice Address - Fax:770-967-8077
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7433225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA857620906EMedicaid
GA202I654821OtherMEDICARE PTAN
GA65BBCNRMedicare ID - Type Unspecified
GAP66695Medicare UPIN