Provider Demographics
NPI:1558484287
Name:BLAKE, KARLA ANNETTE (DT)
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:ANNETTE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:858 STARLIGHT CT
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-2445
Mailing Address - Country:US
Mailing Address - Phone:618-942-5096
Mailing Address - Fax:618-987-4163
Practice Address - Street 1:858 STARLIGHT CT
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-2445
Practice Address - Country:US
Practice Address - Phone:618-942-5096
Practice Address - Fax:618-987-4163
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist