Provider Demographics
NPI:1720280654
Name:BLAKE, HEATHER LEE (MPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26806 BASSWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-2932
Mailing Address - Country:US
Mailing Address - Phone:630-893-5534
Mailing Address - Fax:630-893-5527
Practice Address - Street 1:152 S BLOOMINGDALE RD
Practice Address - Street 2:UNIT 101
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1481
Practice Address - Country:US
Practice Address - Phone:630-893-5534
Practice Address - Fax:630-893-5527
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.012919225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist