Provider Demographics
NPI:1255619490
Name:BLAKE, SHAUN ROLAND (DPT)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:ROLAND
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 SANTA FE DR
Mailing Address - Street 2:STE 120
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5143
Mailing Address - Country:US
Mailing Address - Phone:760-942-4400
Mailing Address - Fax:760-942-4450
Practice Address - Street 1:332 SANTA FE DR
Practice Address - Street 2:STE 120
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5143
Practice Address - Country:US
Practice Address - Phone:760-942-4400
Practice Address - Fax:760-942-4450
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38074225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist