Provider Demographics
NPI:1588829923
Name:CRADY, BLAKE R (RD)
Entity Type:Individual
Prefix:MRS
First Name:BLAKE
Middle Name:R
Last Name:CRADY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 FULLER RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2303
Mailing Address - Country:US
Mailing Address - Phone:734-845-3664
Mailing Address - Fax:
Practice Address - Street 1:2215 FULLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2303
Practice Address - Country:US
Practice Address - Phone:734-845-3664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000001631133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered