Provider Demographics
NPI:1295978542
Name:BLAKE, LORI E B
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:E B
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 1:101 MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2444
Mailing Address - Country:US
Mailing Address - Phone:617-694-5208
Mailing Address - Fax:
Practice Address - Street 1:101 MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2444
Practice Address - Country:US
Practice Address - Phone:617-694-5208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-16
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT2216225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEOT 2216OtherSTATE LICENSE NUMBER
ME433349399OtherMAINE CARE PROVIDER NUMBER