Provider Demographics
NPI:1922632595
Name:BLAKE, SHARON A (CMT)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:A
Last Name:BLAKE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2714 W SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-3252
Mailing Address - Country:US
Mailing Address - Phone:310-357-3358
Mailing Address - Fax:
Practice Address - Street 1:3005 E PALMDALE BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-1831
Practice Address - Country:US
Practice Address - Phone:424-326-5298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-23
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83185225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist