Provider Demographics
NPI:1750795571
Name:BLAKE, ROBERT (PT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-2604
Mailing Address - Country:US
Mailing Address - Phone:440-428-8701
Mailing Address - Fax:
Practice Address - Street 1:3705 STATE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-5957
Practice Address - Country:US
Practice Address - Phone:440-997-0014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06609225100000X, 2251E1300X, 2251G0304X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic