Provider Demographics
NPI:1942770342
Name:BANNER, BLAKE ARIEL (PT)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:ARIEL
Last Name:BANNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:2950 DONNELL DR STE G
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:MD
Practice Address - Zip Code:20747-3277
Practice Address - Country:US
Practice Address - Phone:240-492-3410
Practice Address - Fax:301-278-9852
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27579225100000X
SC8694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist