Provider Demographics
NPI:1639547904
Name:SMITH, BLAKE ERIC (COTA)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ERIC
Last Name:SMITH
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BENA ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-1011
Mailing Address - Country:US
Mailing Address - Phone:413-770-6383
Mailing Address - Fax:
Practice Address - Street 1:169 VALENTINE RD
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-3042
Practice Address - Country:US
Practice Address - Phone:413-445-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008716-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA277684274OtherTRICARE