Provider Demographics
NPI:1649602723
Name:BLAKE, TIMOTHY E (PT, DPT, CSCS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:5899 BREMO RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1935
Practice Address - Country:US
Practice Address - Phone:804-285-2645
Practice Address - Fax:804-287-2786
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208076225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN
VA1649602723OtherMEDICAID QMB ONLY
VAQ44228AMedicare PIN