Provider Demographics
NPI:1760707061
Name:BLAKE, ROBERT MCGOWIN (NMT, LMT, NCTMB)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MCGOWIN
Last Name:BLAKE
Suffix:
Gender:M
Credentials:NMT, LMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 353
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:AL
Mailing Address - Zip Code:35080
Mailing Address - Country:US
Mailing Address - Phone:205-837-3461
Mailing Address - Fax:
Practice Address - Street 1:643 FIRST STREET NORTH
Practice Address - Street 2:
Practice Address - City:ALABASTER
Practice Address - State:AL
Practice Address - Zip Code:35007
Practice Address - Country:US
Practice Address - Phone:205-837-3461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1787225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist