Provider Demographics
NPI:1992223796
Name:BLAKE, DERRICKER
Entity Type:Individual
Prefix:
First Name:DERRICKER
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 1:14 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-4152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3769 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-2041
Practice Address - Country:US
Practice Address - Phone:718-769-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0087221224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant