Provider Demographics
NPI:1538294624
Name:BLAKE, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 TAYLOR FARM RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03087-1266
Mailing Address - Country:US
Mailing Address - Phone:603-244-0025
Mailing Address - Fax:
Practice Address - Street 1:8 TAYLOR FARM RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:NH
Practice Address - Zip Code:03087-1266
Practice Address - Country:US
Practice Address - Phone:603-244-0025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2016-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0762235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH66Y002825NH01OtherANTHEM