Provider Demographics
NPI:1669088100
Name:BLAKE, ANDREA (OTR)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WOODCHUCK LN
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-3427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 WOODCHUCK LN
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-3427
Practice Address - Country:US
Practice Address - Phone:347-604-4574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5513225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist