Provider Demographics
NPI:1134924475
Name:BLAKE, JOHN C
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:BLAKE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2844 MONTCLAIR PL
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-8944
Mailing Address - Country:US
Mailing Address - Phone:414-345-7781
Mailing Address - Fax:866-496-2680
Practice Address - Street 1:50 PEARL AVE STE 102
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-4811
Practice Address - Country:US
Practice Address - Phone:414-345-7781
Practice Address - Fax:866-496-2680
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0017165320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities