Provider Demographics
NPI:1548405707
Name:BLAKE, SANDRA LEONA (AUD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:LEONA
Last Name:BLAKE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3857 PINE CONE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602
Mailing Address - Country:US
Mailing Address - Phone:301-299-6714
Mailing Address - Fax:
Practice Address - Street 1:11604 BUNNELL CT S
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-3603
Practice Address - Country:US
Practice Address - Phone:301-299-6714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00139237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter