Provider Demographics
NPI:1669016887
Name:MCMONAGLE, BLAIZE (PTA)
Entity Type:Individual
Prefix:
First Name:BLAIZE
Middle Name:
Last Name:MCMONAGLE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 MONROE RD UNIT 470738
Mailing Address - Street 2:
Mailing Address - City:LAKE MONROE
Mailing Address - State:FL
Mailing Address - Zip Code:32747-7525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5121 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-8574
Practice Address - Country:US
Practice Address - Phone:407-346-4997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA24352225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant