Provider Demographics
NPI:1942675152
Name:BLAKE, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29468 466TH AVE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:SD
Mailing Address - Zip Code:57014-6308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 VERMILLION ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:SD
Practice Address - Zip Code:57014-2168
Practice Address - Country:US
Practice Address - Phone:605-212-3446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA076277225X00000X
SD0967225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist