Provider Demographics
NPI:1255720744
Name:BLAKE, WENDY
Entity type:Individual
Prefix:
First Name:WENDY
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 1:19472 US ROUTE 11
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5387
Mailing Address - Country:US
Mailing Address - Phone:315-963-0864
Mailing Address - Fax:
Practice Address - Street 1:216 COUNTY ROUTE 64
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-3229
Practice Address - Country:US
Practice Address - Phone:315-963-0864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019414225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics