Provider Demographics
NPI:1023258613
Name:ROSE, BLAKE ILYSA (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ILYSA
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:BLAKE
Other - Middle Name:ILYSA
Other - Last Name:SMALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:139 E 35TH ST
Mailing Address - Street 2:5E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4176
Mailing Address - Country:US
Mailing Address - Phone:516-410-8452
Mailing Address - Fax:
Practice Address - Street 1:139 E 35TH ST
Practice Address - Street 2:5E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4176
Practice Address - Country:US
Practice Address - Phone:516-410-8452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015114235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist