Provider Demographics
NPI:1750893673
Name:BLAKE, AIMEE JEAN (COTA/L)
Entity type:Individual
Prefix:
First Name:AIMEE
Middle Name:JEAN
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 1:4478 FORK RD
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:28128-8456
Mailing Address - Country:US
Mailing Address - Phone:704-984-2816
Mailing Address - Fax:910-428-1165
Practice Address - Street 1:401 LAMBERT RD
Practice Address - Street 2:
Practice Address - City:BISCOE
Practice Address - State:NC
Practice Address - Zip Code:27209-9002
Practice Address - Country:US
Practice Address - Phone:910-428-2117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5248224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant