Provider Demographics
NPI:1992005912
Name:BLAISE, RENEE ADELE (PTA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:ADELE
Last Name:BLAISE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:ADELE
Other - Last Name:BELCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:93 RICHARDS AVE
Mailing Address - Street 2:APT 110
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-1679
Mailing Address - Country:US
Mailing Address - Phone:631-671-9183
Mailing Address - Fax:
Practice Address - Street 1:93 RICHARDS AVE
Practice Address - Street 2:APT 110
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06854-1679
Practice Address - Country:US
Practice Address - Phone:631-671-9183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1123225200000X
NY006887225200000X
MS4636225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant