Provider Demographics
NPI:1568800571
Name:DEIST, BLAKE (DPT)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:DEIST
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7414 W 22ND ST APT 302
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-2641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3050 CENTRE POINTE DR STE 200
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1179
Practice Address - Country:US
Practice Address - Phone:888-974-6636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist