Provider Demographics
NPI:1750705802
Name:BLAKE, TARA (COTA/L)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 SCHUBERT AVE
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-3412
Mailing Address - Country:US
Mailing Address - Phone:330-606-3675
Mailing Address - Fax:
Practice Address - Street 1:2222 ISSAQUAH ST
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-3704
Practice Address - Country:US
Practice Address - Phone:330-606-3675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant