Provider Demographics
NPI:1578742334
Name:BLAKE, PETER CRANSTON
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:CRANSTON
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5766 BRONX AVE
Mailing Address - Street 2:BUILDING A
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-8413
Mailing Address - Country:US
Mailing Address - Phone:904-347-8185
Mailing Address - Fax:
Practice Address - Street 1:5766 BRONX AVE
Practice Address - Street 2:BUILDING A
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-8413
Practice Address - Country:US
Practice Address - Phone:904-347-8185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA51671225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist