Provider Demographics
NPI:1821486218
Name:HINES, BLAKE HARRISON (ATC, NASM-PES, MA)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:HARRISON
Last Name:HINES
Suffix:
Gender:M
Credentials:ATC, NASM-PES, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 MEADOWLANDS DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-9070
Mailing Address - Country:US
Mailing Address - Phone:601-760-2139
Mailing Address - Fax:
Practice Address - Street 1:214 MEADOWLANDS DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-9070
Practice Address - Country:US
Practice Address - Phone:601-760-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT05242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer