Provider Demographics
NPI:1821200270
Name:BLAKE, AMY MICHELLE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MICHELLE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37770 STATE ROUTE 124
Mailing Address - Street 2:
Mailing Address - City:POMEROY
Mailing Address - State:OH
Mailing Address - Zip Code:45769-9302
Mailing Address - Country:US
Mailing Address - Phone:740-992-0840
Mailing Address - Fax:
Practice Address - Street 1:37770 STATE ROUTE 124
Practice Address - Street 2:
Practice Address - City:POMEROY
Practice Address - State:OH
Practice Address - Zip Code:45769-9302
Practice Address - Country:US
Practice Address - Phone:740-992-0840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0012392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer