Provider Demographics
NPI:1609480342
Name:BLAKE, TOMSENE JOHNETTA
Entity Type:Individual
Prefix:
First Name:TOMSENE
Middle Name:JOHNETTA
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7465
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20792-7465
Mailing Address - Country:US
Mailing Address - Phone:202-528-3067
Mailing Address - Fax:
Practice Address - Street 1:12115 SUTTON LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-3562
Practice Address - Country:US
Practice Address - Phone:202-528-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM01119225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty