Provider Demographics
NPI:1750676904
Name:BLAKE, NICOLE MARIE (DPT)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 S DECKER AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-3946
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4924 CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-5908
Practice Address - Country:US
Practice Address - Phone:443-442-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23660225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist