Provider Demographics
NPI:1922023514
Name:HOLLAND, BLAKE (DPT)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:HOLLAND
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 E MAIN ST
Mailing Address - Street 2:SUITE 103-105
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3121
Mailing Address - Country:US
Mailing Address - Phone:631-289-0044
Mailing Address - Fax:631-447-6126
Practice Address - Street 1:475 E MAIN ST
Practice Address - Street 2:SUITE 103-105
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3121
Practice Address - Country:US
Practice Address - Phone:631-289-0044
Practice Address - Fax:631-447-6126
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026993-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ22F01Medicare ID - Type UnspecifiedPHYSICAL THERAPIST